Provider Bulletin - Summer 2014

Bulletin the Acting CEO

Provider

note from

Note from the Acting CEO ..............1 Provider Relations Department.......2

Valley Health Plan (VHP) is fast becoming the local health plan of choice for quality care in Santa Clara County. For the past 29 years, VHP has offered health insurance to nonprofit and governmental Pat Cox employer groups, located throughout Santa Clara County. This past year, VHP expanded beyond insuring only employer groups by adding two new commercial products available to individuals and families living in Santa Clara County.

Your Feedback is Important.............2

This is an historic time in our country, where the Affordable Care Act gives individuals who have not previously had health insurance a way to access doctor’s offices, hospitals, and pharmacies.

VHP is one of only five issuers of Qualified Health Plans in Santa Clara County to be selected to offer Covered California, our State’s insurance marketplace. This opens the door for Santa Clara County residents to shop, compare, and enroll into coverage through VHP. VHP also developed an Individual & Family Plan product which mirrors the unsubsidized cost and benefits plans of Covered California.

Cultural Competencies.....................5

VHP core values will remain that members and providers are among our most important assets. We value each of our providers as you are key to providing the quality care we are known for offering. We thank you for our valued partnership.

VOLUME 16, SUMMER 2014

Improving Practitioner Communication.................................3 New or Departing Providers...........3 Changes in Your Information?........3 Credentialing Process.......................4 Free Interpreter Services...................4 Affirmative Statement About Financial Incentives...........................4 Healthcare Professionals Rights......5 Member Rights and Responsibilities..................................5 Timely Filing of Claims....................6 Authorization Review.......................6 Authorization Denial Disputes........7 Valley Express Access.......................7 Care Management Program.............8 QM Results for HEDIS, Access, Member & Practitioner Experience 2013..................................9 Timely Access Standards................12 Preventive Health Guidelines........13 Personal Health Assessment..........13

Quality Management Program.....14 Pharmacy Corner............................15

Table of Contents

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Valley Health Plan

Provider Relations Department Valley Health Plan’s Provider Relations Department is here for you. We are responsible for managing the Provider Network. Our team is made up of four Provider Relations Specialists that are available to assist you, the practitioner, with questions or information about VHP benefits and member needs.

Specialists answer the phone during business hours and also visit practitioner offices to discuss VHP services and any new Plan developments. There are also two Credentialing Specialists who ensure the VHP practitioners meet the qualifications determined by the Plan to meet regulatory and National Committee for Quality Assurance (NCQA) requirements. This process ensures that all practitioners have been carefully screened to meet industry standards. Practitioners are re-credentialed every three years; however, there is ongoing monitoring of licensing and regulatory changes.

Contact Information

Address:

2480 N. First Street, Ste. 200

San Jose, CA 95131 Telephone: 408.885.2221 Facsimile: 408.793.6648 Email Address: ProviderRelations@vhp.sccgov.org Website: www.valleyhealthplan.org Business Hours:

Monday – Friday, 9am – 4pm

VHP Provider Relations Staff Amarjit Singh, Jamie Albright, Michele Garzoni Welch, Vivian Smith (Manager), Leticia Elisea, Jessica Truong, Rachelle Arquero

your feedback

is Important

We received your feedback from the recent Provider Satisfaction Survey. One area identified by several providers was improving the information on a denial letter. Findings from the survey revealed that the denial letters were not easy to understand. Because of your feedback, we have incorporated some improvements to the letter including information that is now in clearly identifiable sections and who you can contact if you have questions.

Thank you for your participation in our satisfaction survey. We value your input as it helps us improve your experience. When you are able to work more efficiently, ultimately, it will improve the experience and care our members receive.

BOARD OF SUPERVISORS: Mike Wasserman Cindy Chavez Dave Cortese Ken Yeager S. Joseph Simitian COUNTY EXECUTIVE: Jeffery V. Smith

VHP MEDICAL ADVISORS: Dolly Goel, MD Stephen Harris, MD Michael Meade, MD Ginger Roehrig, MD Gary Steinke, MD 2

iMPROVING PRACTITIONER COMMUNICATION for Better Coordination of Care According to the results of VHP’s 2013 Practitioner Satisfaction Survey, only 35% of Primary Care Physicians (PCP’s) who referred a Member to another healthcare practitioner and 14% of PCP’s who referred a member to a behavioral healthcare practitioner reported that they usually or always received information back from the referring healthcare practitioner including behavioral healthcare practitioner.

health records between the practitioners who are providing their care.

Go to www.valleyhealthplan.org on the Provider or Member page under Forms and Resources to print it out. Take the time to explain how important it is that you receive the information to coordinate your patient’s care.

VHP believes that improving communication between PCP’s; other health care practitioners and behavioral healthcare practitioners play a critical part in improving a Member’s overall health.

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VHP would like to assist you in this process by encouraging Members to share their information with those providing their medical/behavioral health care. To do this, VHP has posted a form on www.valleyhealthplan.org called Authorization for Use and/or Disclosure of Protected Health Information. This form will give Members an authorized way to share their medical/behavioral

new or departing Providers When practitioners join or leave their practice, VHP Provider Relations must have a 60 day notice in order to complete timely credentialing and/or properly notify the network of the departure and coordinate the care for our Members. To notify Provider Relations of any changes to your practice, please email ProviderRelations@vhp.sccgov.org or call 408.885.2221, Option 2.

changes

in Your Information?

It is critical that VHP has the most up to date address, telephone, and fax number for you and your practice.

Medical Group Affiliation: If you are affiliated with a contracted Medical Group, please contact them directly and make sure they provide the information to VHP. Other Contracted Providers: If you are not associated with a medical group or are an independent provider, please submit, on your business letterhead, a letter that includes your signature and what the changes are along with the effective date of the change.

VHP Provider Relations

t r o p e R anges Ch 2480 N. First Street, Ste. 200 San Jose, CA 95131 Fax to: 408.793.6648 Email to: ProviderRelations@vhp.sccgov.org 3

credentialing Process Files that meet established credentialing criteria will be presented to the Chief Medical Officer on a monthly basis for review and subsequent approval. All practitioners must be approved and actively credentialed before providing care to VHP Members. All active practitioners are re-credentialed every three years. Please reply promptly to credentialing inquiries to prevent a delay in the process.

how to access Free Interpreter Services Interpreter services are available 24 hours a day, 365 days a year for VHP Members when accessing VHP covered services. It’s important that practitioners do not use untrained bilingual staff, family members, or friends to interpret for patients. Using an untrained interpreter can result in miscommunication of medical information, which could compromise quality of care.

In addition, using family members or friends can cause embarrassment or reluctance to disclose important information.

Practitioners can access interpreter services by calling the language line at 408.278.9927 and entering the assigned access code. If you do not know your access code, please contact Provider Relations at ProviderRelations@vhp.sccgov.org or 408.885.2221, Option 2 Monday - Friday 9am – 4pm.

Tips for Using Telephone Interpreters: • Allow some extra time for the visit if you know an interpreter will be needed; • Introduce the patient and brief the interpreter about the type of visit or service; • When communicating with the patient, speak directly to the patient, not the interpreter; • Frequently ask the patient if he or she has any questions; • Avoid medical jargon or technical terms.

affirmative statement About Financial Incentives Valley Health Plan affirms that: 1. Utilization Management (UM) decision making is based only on appropriateness of care and service and existence of coverage.

2. The Plan does not specifically reward practitioners or other individuals for issuing denials of coverage.

3. Financial incentives for UM decision makers do not encourage decisions that result in underutilization.

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notice to healthcare professionals of Your Rights

Healthcare professionals have the right to review information obtained by Valley Health Plan (VHP) to support their credentialing application and obtain the status of their application throughout the credentialing process. If you would like to review the information obtained by VHP, please call Provider Relations to set up a time to meet.

You will be given the opportunity to correct any erroneous information obtained during the verification process. VHP will notify you of any information that varies substantially from the information you personally provided on the credentialing application. You will be given 30 days to provide a written response to the person specified on the notification and that information will be included and reviewed by the Credentialing Committee.

To receive information about the status of a credentialing or recredentialing application, or if you have any questions about the process or these rights, please contact the VHP Provider Relations Department at ProviderRelations@vhp.sccgov.org or 408.885.2221 Option 2, Monday – Friday, 9am – 4pm.

member rights and Responsibilities A list of Member Rights and Responsibilities can be found on our website www.valleyhealthplan. org/sites/providers/fr/Pages/mrr.aspx. You can also contact VHP Provider Relations Department at ProviderRelations@vhp.sccgov.org or call 408.885.2221, Option 2, Monday – Friday, 9am – 4pm for a copy.

cultural Competencies

Tips and Resources to Help You Communicate Better with Valley Health Plan Members.

The National Lesbian, Gay, Bisexual, and Transgender (LGBT) Health Education Center has free learning modules specifically for healthcare professionals. Valley Health Plan encourages practitioners to access the various learning modules as they were created to help facilitate the teaching of LGBT health topics to healthcare professionals and students. You can download the modules from www.lgbthealtheducation. org/training/learning-modules and use them in your courses, trainings, and workshops, or use for selfdirected learning.

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Timely Filing of Claims Valley Health Plan follows all Department of Managed Health Care (DMHC) regulations when it comes to the payment of claims. Please submit your claims as soon as possible in order to expedite payment.

Contracted practitioners must submit claims within 90 calendar days following the date of service unless otherwise mandated by law or in the practitioner contract. A claim received after the 90 days billing time limit is subject to denial. Claims are normally paid within the time frames outlined in your contract.

Non-contracted practitioners must submit claims within 180 calendar days following the date of service.

If you have any additional questions, please contact the VHP Claims Department Monday – Friday, 9am – 4pm, at 408.885.4563.

WHERE TO MAIL CLAIMS: VHP Employer Group Plan P.O. Box 26160 San Jose, CA 95159 VHP Covered California Plan P.O. Box 650864 Dallas, TX 75265 VHP Individual & Family Plan P.O. Box 650864 Dallas, TX 75265 VHP Medi-Cal P.O. Box 28407 San Jose, CA 95159 VHP Healthy Kids P.O. Box 28410 San Jose, CA 95159

Authorization review

Criteria and Decision Making Process VHP ensures that medical necessity decisions affecting the health care of Members are made in fair, impartial and consistent by using objective measurable criteria based on reasonable medical evidence.

Authorization requests are reviewed by the VHP Utilization Management (UM) staff to determine the medical necessity for requested services. The plan uses the following criteria sets to assist in this determination: • InterQual • Apollo Criteria • Milliman Care Guidelines 6

Valley Health Plan can provide copies or paraphrase the section when copyright restrictions apply, of the criteria applicable to the specific procedure or conditions requested.

Please contact the UM Department Monday through Friday 9am – 5pm at 1.888.421.8444 (toll-free).

Visit our website at www.valleyhealthplan.org for the entire VHP Policy and Procedure or contact UM at 1.888.421.8444 (toll-free).

authorization Denial Disputes If an authorization is denied, a provider may request reconsideration of denied services in writing through the Provider Dispute process.

Each dispute must contain the following information: • Provider name • Provider identification number (NPI) • Provider contact information • Member name and Plan ID • Original authorization number • Reason for dispute • Any documentation supporting the dispute Disputes must be submitted in writing to the following address: Valley Health Plan Provider Relations Dispute Resolution P.O. Box 28387 San Jose, CA 95159

valley express Access

With the growing need for practitioners to have access to electronic services that offer improved control, convenience, and flexibility, VHP maintains a constant focus on technological innovation.

VHP’s Valley Express is tailored to meet your needs and provide the tools and information needed to make the business of healthcare easy.

Valley Express will allow you to: • Check member eligibility • Create referrals • Create authorizations • Search referrals • Search authorizations • Submit clinical documentation with referrals and authorizations To set up an account, please contact Provider Relations at ProviderRelations@vhp.sccgov.org or 408.885.2221, Option 2, Monday–Friday, 9am–4pm.

Accounts are created within 48 hours once the

A Provider Dispute will be acknowledged in writing to the provider within 15 business days and a resolution will be sent to the provider within 45 business days.

Provider Disputes that do not include all required information may be returned for additional information. VHP will clearly identify in writing to the provider the missing information necessary to resolve the dispute. Providers can submit an amended dispute including the missing information within 30 business days. Please contact Provider Relations Monday – Friday, 9am – 4pm at 408.885.2221, Option 2, with any additional questions or concerns.

Discussing an Authorization Denial or Potential Authorization Denial If you would like to discuss an authorization denial or potential authorization denial, you can contact the VHP Chief Medical Officer at 408.885.4647.

necessary information is obtained. Each individual staff member must have their own account and should not share accounts or passwords.

Valley Express Provider Portal Referral and Authorization Submission You can submit referrals and authorizations through the Valley Express Provider Portal. You may submit documentation after you submit your request, however, to ensure timely processing, please remember to electronically attach clinical documentation at the time of submission by scrolling down to the bottom of your request and click “add attachments”.

Please confirm that all information is thorough and complete before submitting your request and include the submitter’s contact information.

If you have questions, or if your office is in need of access or training, please contact your Provider Relations liaison at ProviderRelations@vhp.sccgov. org or 408.885.2221, Option 2, Monday – Friday, 9am – 4pm.

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CARE MANAGEMENT Program NEW Valley Health Plan Care Management Program works with Members to improve their health and quality of life. Our program consists of complex case management, care coordination and preventive health education, including chronic disease selfmanagement. The Care Management Program encompasses two programs: Disease Management and Complex Case Management. VHP has partnered with McKesson Care Management to co-administrate these programs. McKesson is a leading provider of disease and care management services, offering more than 25 million enrolled patients immediate access to a broad range of health and disease management services. The Care Management Program is delivered by a team of specially trained registered nurses and other professional staff, using state-of-the-art information systems to provide knowledge, support, and monitoring for patients between practitioner visits.

Members are identified for the Complex Case Management and Disease Management programs through historical claims data (medical and pharmacy) along with requests for services requiring prior authorization and use of the health information line for members with high and/or complex needs.

The Disease Management Program is a care management program that partners with medical practitioners and is designed to support patients by helping them with chronic medical conditions to improve and better manage their health.

This program promotes adherence to the primary care practitioners’ treatment plans for patients who have chronic conditions such as: • Asthma • Bipolar Disorder • Chronic Obstructive Pulmonary Disease (COPD) • Coronary Artery Disease • Depression • Diabetes • Heart Failure • Schizophrenia

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Valley Health Plan has adopted the following clinical guidelines for practitioners’ use for diagnostic and treatment purposes: 1) Coronary artery disease 2) Diabetes 3) Depression 4) Attention Deficit Hyperactivity Disorder (Children and Adolescents) The Complex Case Management Program has McKesson care managers working with Members along with their caregivers and their physicians to coordinate care, educate members, transition smoothly between care settings, and assist with community resources, and other social needs. The goals are to help your patient navigate the health care system along with encouraging adherence to their treatment plan, to decrease hospitalizations and unneeded use of emergency rooms.

These programs are a benefit and a FREE service provided to eligible patients. Patients who do not wish to participate in the program can opt out of the program at any time. Eligible patients are identified and stratified by chronic condition risk levels using historical claims data. We appreciate practitioner input on identifying eligible patients, along with validating conditions identified and care plan needs.

We can receive this input by phone 1.855.624.5223 or through a secure fax line at 1.800.542.8074. The Care Management Program hours are Monday - Friday, 8am – 8pm and Saturdays from 8am – 12pm.

These programs were designed using current, nationally recognized evidence-based clinical guidelines. Please refer to the Valley Health Plan website www.valleyhealthplan.org to review the clinical guidelines. If you would like paper copies of the clinical guideline summaries, please contact the Care Management Program at 1.855.624.5223.

Members and caregivers may also self-refer to the VHP Care Management Program by calling 1.855.624.5223.

QUALITY MANAGEMENT RESULTS

for HEDIS, Access, Member and Practitioner Experience 2013 In 2013, Valley Health Plan continued to monitor their Healthcare Effectiveness Data and Information Set (HEDIS) scores for quality improvement, as well as practitioner access standards, Member and practitioner experience with Valley Health Plan in order to continuously improve the quality of care for VHP members.

Scores provided below are from the 2013 HEDIS Report, 2013 Access Reports, and the 2013 EMC Research Member and Practitioner Experience (Satisfaction) Survey.

For more information about HEDIS and their measures, please visit the National Committee for Quality Assurance (NCQA) website at www.ncqa.org EFFECTIVENESS OF CARE MEASURES The information displayed below provided the percentage of our commercial Members who received the indicated services and the national averages currently available.

Valley Health Plan HEDIS Results

5Oth Percentile Quality Compass® National Average

92.6%

85%

25.5%

21%

98%

92%

79.3%

88%

Breast Cancer Screening

65.4%

70%

Cervical Cancer Screening

66.9%

77%

Colorectal Cancer Screening

56.9%

63%

66.7%

60%

41.3%

44%

91%

94%

83.8%

86%

64.7%

66%

63.8%

61%

91.3%

89%

CATEGORY/MEASURE MEDICATION MONITORING Appropriate Treatment for Children with Upper Respiratory Infection Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis Use of Appropriate Medications for People with Asthma - Total Disease Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis SCREENINGS

IMMUNIZATION STATUS Immunizations for Adolescents - Combination PRENATAL AND POSTPARTUM CARE Chlamydia Screening in Women - Total Prenatal and Postpartum Care – Timeliness of Prenatal Care Prenatal and Postpartum Care – Postpartum Care CARDIOVASCULAR MONITORING Controlling High Blood Pressure – Total Cholesterol Management for Patients with Cardiovascular Conditions: LDL-C Control (‹100mg/dL) Cholesterol Management for Patients with Cardiovascular Conditions: LDL-C Screening

(Continued on pg. 10) 9

(Continued from pg. 9)

Valley Health Plan HEDIS Results

5Oth Percentile Quality Compass® National Average

Comprehensive Diabetes - HbA1c Testing

89.5%

90%

Comprehensive Diabetes - LDL Screening

85.3%

85%

Comprehensive Diabetes - Medical Attention for Nephropathy

79.9%

84%

Comprehensive Diabetes - Poor HbA1c Control ›9% Comprehensive Diabetes - HbA1c Control ‹8 Comprehensive Diabetes - HbA1c Control ‹7% Comprehensive Diabetes - LDL-C Controlled (LDL-C ‹100mg/dL) Comprehensive Diabetes – Blood Pressure Control (‹140/90)

23.9% 67.4% 48.8% 50.5% 69.6%

27% 63% 43% 48% 67%

7.8%

15%

30.5%

41%

63%

65%

46.3%

48%

67.9%

64%

CATEGORY/MEASURE DIABETES MANAGEMENT

ALCOHOL & OTHER DRUG MONITORING Initiation & Engagement of Alcohol & Other Drug Dependence Treatment – Engagement Total Initiation & Engagement of Alcohol & Other Drug Dependence Treatment – Initiation Total BEHAVIORAL HEALTH MONITORING Antidepressant Medication Management – Effective Acute Phase Treatment Antidepressant Medication Management – Effective Continuation Phase Treatment WEIGHT/NUTRITION/PHYSICAL ACTIVITY MONITORING Adult BMI Assessment (Total)

USE OF SERVICE Valley Health Plan encourages Members to take advantage of important preventive care services.

Valley Health Plan HEDIS Results

5Oth Percentile Quality Compass® National Average

Well-Child Visits in the first 15 months of life (6 or more visits)

90.2%

81%

Well-Child Visits in the 3rd, 4th, 5th, and 6th Years of Life

79.1%

75%

Adolescent Well-Care visits

48.9%

41%

CATEGORY/MEASURE

ACCESS/AVAILABILITY OF CARE Valley Health Plan Members have access to a various network of practitioners in order to address their healthcare needs. During 2013, specialty physician appointment rates decreased to 76% from 85.5% (2012).

This rate decrease is linked to one of the plan’s largest specialty service providers who implemented an Electronic Health (EHR) Record during the year. The implementation phases of the EHR required clinic appointments to be reduced over a six (6) week period. When timely access standards are not met, a corrective action plan is submitted and reviewed by the Quality Management Committee.

(Continued on pg. 11) 10

CATEGORY/MEASURE

MET CA STANDARD VHP GOAL

Primary Care Physician Appointments Urgent: CA STANDARD (48 hours no prior authorization and 96 hours prior authorization required)

Urgent

100%

90%

Non-Urgent: CA STANDARD (10 Business Days)

Non-Urgent

84%

90%

76%

90%

Specialty Physician Appointments Non-Urgent: CA STANDARD (15 Business Days)

MEMBER EXPERIENCE WITH CARE VHP Member experience continues to demonstrate satisfaction with the Plan. Awareness about behavioral health services continue to be low at 61%. As a practitioner, we ask you to advise our Members that they can access Outpatient Behavioral Health Services (outpatient counseling services) without a referral. Members can contact a VHP Behavioral Health Provider directly. For Psychiatry services, Members will need prior authorization to a Plan practitioner before seeking care.

N=500 PARTICIPANTS

RATING

VHP GOAL

Rating of Health Plan (strongly & somewhat favorable)

86%

90%

Satisfaction with Health Plan (very satisfied & satisfied)

76%

90%

Primary Care Physician (best possible & good) Specialist (best possible & good) Health Care (best possible & good) Availability of Information in Your Language Member Awareness of Behavioral Health Services

87% 86% 84% 79% 61%

90% 90% 90% 90% 90%

PRACTITIONER EXPERIENCE Practitioners’ experience continues to demonstrate an overall high satisfaction which is consistent with previous years. Satisfaction with claims services has improved overall in the past year (Example: Timeliness of claims payment: 2012 - 51% (very satisfied and somewhat satisfied) and 2013 – 63% (very satisfied and somewhat satisfied).

As a result of this year’s findings, three areas were identified for 2014 quality improvement (QI) activities for the plan. These QI activities include: 1) VHP denial letters, 2) Coordination of Care between Practitioner to another Medical Healthcare Practitioner, and 3) Coordination of Care between Practitioner and Behavioral Healthcare Practitioner.

N=80 PARTICIPANTS OUT OF 3,000 SURVEY INVITATIONS Satisfaction with the Health Plan (very satisfied & somewhat satisfied) Practitioners who had received a denial letter – denial reason easy to understand (yes) Practitioners who had referred a patient to another healthcare practitioner: how often did they received information from the health practitioner to coordinate care (always and usually) Practitioners’ who had referred a patient to a behavioral healthcare practitioner: how often had they received information from the behavioral healthcare practitioner to coordinate care (always and usually) NOTE: Sometimes response = 50%

RATING

VHP GOAL

75%

90%

56%

90%

35%

90%

14%

90%

When contacted by VHP to participate in the VHP Practitioner Satisfaction Survey, we truly appreciate the time you take to complete it. Your feedback is very important to us. Information collected from surveys can assist us to identify where improvements are needed and what we are doing well. The time you take to participate in the annual Practitioner Survey will benefit both you and the Members you serve and help to make VHP the health plan of choice in our community. Thank you.

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TIMELY Access

Standards

­­

Below are a variety of Timely Access Standards Regulations for the State of California. The Quality Management Department would like you to review these so you understand what our Members are expecting from your services.

Appointment Scheduling Emergency Services

Immediately

Urgent Care appointments that do not require prior authorization from a Primary Care Physician (PCP)

Within 48 hours of request

Urgent Care appointments that require prior authorization

Within 96 hours of request

Non-Urgent appointments for PCP Non-Urgent appointments with Specialist Physicians (SCP) Non-Urgent appointments for Ancillary Services (for diagnosis or treatment of injury, illness, or other health condition) Waiting Time in Practitioner Office (Appointment time until the member sees the practitioner.)

Accessibility of Obstetrical Care Emergency Exam

Within 10 business days of request Within 15 business days of request With 15 business days of request Maximum 30 minutes Maximum Waiting Time Immediately

Initial Visit

Within 30 calendar days

Non-Urgent subsequent Exams

Within 30 calendar days

Availability of Behavioral Health Care Life threatening Emergency Non-Life threatening Emergency Urgent Care appointments Non-Urgent Care appointments with a non-physician Mental Health Care Practitioner Non-Urgent appointments with Physician Mental Health Care Practitioner Access to Follow-up care after hospitalization for mental illness

After-Hours Care

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Maximum Waiting Time

Maximum Waiting Time Immediately Within 6 hours Within 48 hours of request Within 10 business days Within 15 business days Must Provide Both: • One follow-up encounter with a mental health provider within 7 calendar days after discharge.

• One follow-up encounter with a mental health Practitioner within 30 calendar days after discharge.

Nurse Advice Line is available 24/7 at 1.866.682.9492 (toll-free) including all holidays, weekends, and after hours care.

(Continued on pg. 13)

As well as the information on page 12, the following is additional information included in the Timely Access Standards: Contracted Hospitals and Physicians, Including Specialized Mental Health Providers These services need to ensure 24 hours per day, 7 days per week, triage or screening services by telephone which includes: 1. Provided in a timely manner appropriate to the Member’s condition, and that the triage or screening wait time does not exceed 30 minutes (Triage or screening wait time means the time to waiting to speak by telephone with a physician, registered nurse, or other qualified health care professional).

2. Caller will be informed regarding the length of wait for a return call from the provider.

3. How the caller may obtain urgent or emergency care, including, when applicable, how to contact another provider who has agreed to be on-call to triage or screen by phone, or if needed, deliver urgent or emergency care.

4. Unlicensed staff persons handling Member calls may ask questions on behalf of a licensed staff person in order to help ascertain the condition of an enrollee so that the Member can be referred to licensed staff. However, under no circumstances shall unlicensed staff persons use the answers to those questions in an attempt to assess, evaluate, advise, or make any decisions regarding the condition of an enrollee or determine when a Member needs to be seen by a licensed medical professional.

Ancillary Service Providers - Chiropractic and Acupuncture Providers These services need to ensure they have an answering service or telephone answering machine during non-business hours, which provide instructions regarding how a Member may obtain urgent or emergency care including, when applicable, how to contact another provider who has agreed to be on-call to triage or screen by phone, or if needed, deliver urgent or emergency care.

We want to thank you for striving to provide our Members with access to your offices and also for your commitment to providing high quality care. We will continue to work with you in the coming year to ensure our Members have the access they required to meet their healthcare needs.

preventive health

Guidelines

VHP Providers have access to the most current preventive health guidelines through the VHP Provider Portal. These guidelines are updated annually by the Utilization Management Committee that includes practicing physicians. These guidelines are based on those from the Centers for Disease Control (CDC) and the United States Preventive Services Task Force (USPSTF). We encourage use of these guidelines, as in the future, VHP will be graded through the accreditation process based on the adherence to the national guidelines. If you are interested in being involved in the committee that annually reviews these guidelines and those for utilization management, please call the VHP Provider Relations department Monday – Friday, 9am – 4pm at 408.885.2221, Option 2.

personal health assessment

for VHP Members

VHP has partnered with Cerner Wellness to offer VHP Members a wellness solution to help them meet their unique needs and wellness goals. As Members complete different levels, they will earn VHP rewards like a workout towel and other items. They can earn rewards by completing a Personal Health Assessment (PHA), taking online workshops, logging food and water intake, getting their annual health screenings and more.

If you would like to take a look online, go to vhp.mycernerwellness.com Please encourage your VHP Members to check it out!

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Quality Management

Program

The purpose of the VHP Quality Management (QM) program is to ensure that Members have access to and receive high-quality timely health care, including medical and behavioral health care, which meets all their needs and adheres to recognized standards of care.

QM Program Values The QM program reviews, analyzes, and summarizes data continuously and is aligned with Valley Health Plan’s mission “To ensure that our Members receive the quality of care and service, at the right time, at the right place, by the right provider“. QM program values that help us achieve this vision are: • Caring about the individuals and the families we serve as well as caring for them; • Working in an organization where everyone cares and everyone counts; • Workforce competence to accomplish results and sustain service excellence; and • Respect for our members by upholding their privacy and dignity.

QM Program Goals and Outcomes Valley Health Plan’s QM program goals are to offer high quality care and service that: • Focus on quality measures that make a difference for our Members; • Meet Members’ expectations; and • Ensure that medical and behavioral health services are provided in a caring, cost-efficient and accessible manner.

VHP continues to make progress in meeting its QM program goals by reviewing indicators for clinical care and member/doctor satisfaction. Recent results from the Healthcare Effectiveness Data and Information Set (HEDIS) show improvements from 2012 to 2013 in measures such as: • Immunizations for adolescents; • Timely care for infants; • Controlling cholesterol for Members with heart conditions; and • Diabetes care.

Member satisfaction rates remained high overall from 2012 to 2013. The 2013 survey findings revealed that 86% of our Members’ gave a positive rating to VHP. In 2013 VHP achieved the National Committee for Quality Assurance (NCQA) Interim Accreditation.

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This accreditation is the most comprehensive evaluation in the nation and is based on results achieved in a set of clinical and consumer measures.

Accreditation is an indicator of a high quality organization.

QM Program Activities Patient Safety VHP advocates a collaborative approach to foster a culture of patient safety and promote high quality care. VHP monitors clinical performance indicators like practitioner credentialing to ensure a safe delivery system of doctors. VHP also monitors the Pharmacy Safety program to ensure that our members get the right type and amount of medication they need, along with notifying members quickly of medication recalls. In the 2013 Member and Provider Satisfaction Survey, coordination of care between primary care doctors and behavioral health practitioners was identified as a concern.

Some members who received behavioral health care reported that their doctor never received any information about these services. This concern was referred to the VHP Behavioral Health Management Group (BHMG) that oversees the entire behavioral health program to look for improvement activities.

The plan is to have the BHMG get input for community behavioral health practitioners in 2014 and come up with new improvement activities.

Thank you for your feedback to help improve the health plan and the care of our Members.

Access and Availability VHP monitors our doctors to ensure that they comply with California’s timely access law. VHP is responsible for ensuring that our network is sufficient to help members receive covered services in a timely manner. Member and provider satisfaction surveys are completed annually to rate doctors in VHP’s contracted medical groups. The Provider Access Appointment Availability Survey is also completed each year. In the 2013 Member satisfaction survey, getting appointments with specialists continued to be an area where some Members reported difficulty. VHP is assessing its network of providers and will add available providers to meet

Members’ needs. Members experiencing this type of difficulty are encouraged to contact VHP’s Member Services at 1.888.421.8444 (toll-free).

Health Management Programs VHP has Disease Management and Complex Case Management programs available to meet the healthcare needs of its Members with complex health conditions or chronic diseases through communication, education and resources. If you would like more information about our disease management and complex case management programs, please contact VHP Member Services at 1.888.421.8444 (toll-free).

members to get the care that research shows will help them to stay healthy.

These guidelines can be found on our website at www.valleyhealthplan.org under I’m a Provider, Clinical Guidelines.

VHP welcomes your feedback and suggestions on how to improve performance. If you have any recommendations or comments on this or other VHP documents, please contact Member Services at 1.888.421.8444 (toll-free).

pharmacy

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Performance Measurement Valley Health Plan’s performance is measured through the Healthcare Effectiveness Data and Information Set (HEDIS) and Consumer Assessment of Healthcare Providers and Systems (CAHPS).

HEDIS is one of the most widely used sets of health care performance measures in the United States.

HEDIS includes 75 measures across several aspects of care including Effectiveness of Care, Access/ Availability of Care, Use of Services and Cost of Care. Results are used to identify opportunities for improvement. Quality interventions include educational initiatives for both Members and providers. VHP has started using these national performance measures. CAHPS is the national member satisfaction survey that VHP will be using.

This will allow VHP to compare its results with other health plans across the United States. VHP will be able to see whether there is any way to help our Members get the care that research shows is quality care and to see if our Members are as satisfied with the way we do business as compared to other health plan ratings. If you are contacted for a survey, please invest the short period of time to give feedback and help make us the plan of choice in the community.

Preventive Health and Clinical Practice Guidelines Preventive health and clinical practice guidelines are reviewed and updated annually using the most current and reasonable published medical evidence and the U.S. Preventive Services Task Force recommendations. These guidelines help our doctors, staff and Members to make decisions about the appropriate health care for the Members’ medical condition. In the future we will be scored during the NCQA accreditation process on how we help our

Navitus Health Solutions Navitus Health Solutions is Valley Health Plan’s (VHP) Pharmacy Benefit Manager (PBM). Navitus Health Solutions administers the pharmacy benefit on behalf of VHP, including customer service, formulary maintenance, Prior Authorization, Exception to Coverage, and drug recall notification.

Navitus Customer Care is available to answer your pharmacy benefit questions 24/7, except Thanksgiving and Christmas Day, at 1.866.333.2757 (toll-free).

Immunization Benefits and Services VHP encourages our Members to get the required immunizations as recommended by the United States Preventive Services Task Force to help keep them healthy. Coverage includes immunizations provided by you, their Primary Care Practitioner (PCP), or through a VHP Plan Pharmacy.

Travel immunizations are covered only when received through you, the practitioner, or at a VHP Plan Pharmacy. (*Please note that travel immunizations received from the Santa Clara County Public Health Travel Clinic at Lenzen are not covered by VHP.) Visit www.valleyhealthplan.org to find a Plan Pharmacy. For more information, please call Navitus Customer Care at 1.866.333.2757 (toll-free).

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Provider Relations

2480 N. First Street, Suite 200 San Jose, CA 95131 408.885.2221 ProviderRelations@vhp.sccgov.org www.valleyhealthplan.org

Š 2014 Valley Health Plan

Formulary Review and Updates The Valley Health Plan (VHP) drug formulary is reviewed quarterly and updated by the VHP Pharmacy and Therapeutics (P&T) Committee.

The P&T Committee uses information from many sources to determine the status of each drug. The Committee decisions include adding drugs to the formulary, requiring prior authorization for some drugs, requiring quantity limits or step therapy, our process for generic substitution, therapeutic interchange, or not adding the drug to the formulary. These decisions are based on U.S. Food and Drug Administration (FDA) approval, scientific articles, drug safety, and whether there are other like drugs available that accomplish similar results.

Occasionally, VHP will require you, the provider, to fill out a Prior Authorization form for our Formulary drugs or an Exception to Coverage form for drugs that are not on our drug Formulary. These forms will be reviewed by a pharmacist and/or a physician and approval will be based on established criteria and medical necessity.

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VHP posts a drug formulary and a summary of updates to the website quarterly after each VHP P&T meeting. Visit www.valleyhealthplan.org for additional information or to view the drug Formulary, summary of updates, and the EOC online.

If you do not have access to the internet and would like a hard copy of any material, please call Navitus Customer Care at 1.866.333.2757 (toll-free).

Drug Recall Navitus receives notification from the U.S. Food and Drug Administration’s (FDA) recall posting. VHP Members and prescribing practitioners affected by a Class II recall or voluntary drug withdrawals from the market for safety reasons will be identified and notified within 30 calendar days of the posting, and within two business days for a Class I recall.

Please visit www.navitus.com if you would like additional information on a recent recall.