Provider Bulletin - Summer | Fall 2015 Vol. 18

Bulletin

Provider

message from THE

the stealth part! I hope you’ll join me in spreading the word that, especially with our qualification as a Covered California Health Plan Issuer, VHP is ready and New CEO eager to step out and be discovered by all In my fourth month on the job of those in Santa Clara County who could benefit from our services. as the CEO of Valley Health Plan (VHP), it’s a privilege Thank You, to be able to send out a greeting to the members of our provider network. I look forward to meeting many Message From the New CEO .................. 1 of you and working with Bruce Butler, CEO you in the coming months Timely Access Standards......................... 2 and years, as we jointly pursue the task of offering Patient Follow-Up Post Emergency very high-quality as well as highly-affordable health Department Visit....................................... 4 benefits to residents and workers in Santa Clara 2014 Provider Appointment Availability County, regardless of whether they come to us Survey Results.......................................... 6 through safety-net programs such as Medi-Cal, through Covered California, or through major area Disease Management and Complex Case Management Programs ................. 8 employers. Several priorities I would like to invite you to participate in with VHP include: Quality Management HEDIS Quick • The development of a new suite of products that will support consumer decision-making and choice among provider options.

• Exploration of emerging forms of improving access to health care such as telemedicine, but without loss of coordination of care.

• Metrics-driven collaboration to improve the care process for our members and your patients.

Last but not least, VHP will be celebrating its 30 Anniversary this coming autumn. I believe this might qualify us as the most successful “stealth start-up” in the history of Silicon Valley – at least based on

Reference Guide....................................... 9

VHP Listens.............................................12 QNXT & ICD-10 Updates.........................13 Immunization Benefits and Services Update .....................................13 My Cerner Wellness.................................14 Pharmacy Corner.....................................15

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VOLUME 18, SUMMER | FALL 2015

Table of Contents

TIMELY Access Standards 足足 Below is the Summary of Timely Access Standards Regulations for the State of California. The Valley Health Plan (VHP) Quality Management Department would like you to review the following standards in order for you to better understand these requirements.

Appointment Scheduling Emergency services

Immediately

Urgent Care appointments that do not require prior authorization from a Primary Care Practitioner (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 Specialty Care Physicians (SCP) including Obstetrical Care Non-urgent appointments for Ancillary Services (for diagnosis or treatment of injury, illness, or other health condition) Office/Clinic Wait Time (From appointment registration time to when seen by the practitioner/doctor.)

Availability of Behavioral Health Care practitioners Life threatening emergency Non-life threatening emergency Urgent Care appointments Non-urgent appointments with a non-physician Behavioral Health Care Practitioner (Psychologist, MFT, LCSW) and Psychiatrist

After-Hours Care 24/7 Nurse Advice Line

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Maximum Waiting Time

Within 10 business days of request Within 15 business days of request Within 15 business days of request

Maximum 30 minutes (VHP Standard)

Maximum Waiting Time Immediately Within 6 hours Within 48 hours of request Within 10 business days

AVAILABILITY Call 1.866.682.9492 (toll-free) including all holidays and weekends.

Apart from the synopsis of Department of Managed Health Care’s (DMHC) and the new National Committee for Quality Assurance (NCQA) Behavioral Health Timely Access Standards for Psychiatrists, the VHP QM Department would like to share additional information to help you better understand.

Contracted Hospitals and Physicians, Including Specialized Mental Health Practitioners 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 practitioner.

3. How the caller may obtain urgent or emergency care, including, when applicable, how to contact another practitioner 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 Practitioners 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 practitioner 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 helping us meet our Members’ care needs during the previous year and for your commitment to providing high quality care. We will continue to work with you in the coming year to ensure our Members have access to the services they require to meet their healthcare needs.

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patient follow-up Post Emergency Department Visit Our goal is to encourage Members to see their Primary Care Practitioner (PCP) for follow-up care after an Emergency Department (ED) visit to avoid fragmented care.

A growing body of literature focused on safety and error prevention have revealed that ineffective or insufficient communication among team members is a significant contributing factor to adverse events.

In addition, research indicates that there is a strong correlation between a healthcare team member’s communication skills and a patient’s capacity to follow through with medical recommendations, self-manage a chronic medical condition, and adopt preventive health behaviors.

Valley Health Plan (VHP) would like to work collaboratively with you to enhance the relationship that you have established with our Members and improve their coordination of care. As you know, care coordination is a set of activities that is needed to minimize the dangers of fragmentation. Activities include assuring that all practitioners involved in a patient’s care share important clinical information and have clear expectations about each practitioner’s role.

They also include efforts to keep patients and families informed, and to optimize their experience through care transitions.

VHP is aware that certain barriers exist to effectively transfer patients from the ED to the primary care setting. This includes issues like the patient’s medical records are not always transferred to their PCP after an ED visit. As a result, the PCP is unable to manage the patient’s care and be involved in any necessary follow-up care. In addition, there are times when follow-up appointments with a PCP may not occur in a timely fashion.

Some reasons this may occur are: • there is a change in the phone number or living situation of the patient; • there is not enough time or resources for the practitioner to adequately educate the patient who may have complex health needs and require a follow-up; and • the patient may not fully understand their discharge instructions.

In order to help avoid unnecessary ED utilization and eliminate uncoordinated care, VHP recommends that you share the following information with your patients.

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1. Appropriate Usage of ED versus Urgent Care Centers (UCC) In certain situations, UCC may be a good alternative to the ED as they can address emergent and/or urgent conditions. They also may include diagnostic imaging and laboratory tests capability comparable to the network EDs. Your patient may not be aware of UCC hours and locations. Without knowing the hours and locations, patients are unable to choose alternatives to the ED. Please let your patients know that most UCCs have extended operating hours and are open on weekends and holidays.

We also encourage you to remind your patients that UCCs have walk-in hours so appointments may not be necessary. Lastly, please emphasize that wait times are normally shorter than in the ED and it is a covered benefit if a contracted provider is used.

2. EDs are not equipped for the long term management of complex or chronic illnesses.

If you have a patient who has been frequenting the ED, consider referring them to VHP’s Complex Case Management or Disease Management Programs. These programs are readily available to VHP Members and if needed, will be assigned a nurse to work with to achieve optimum health.

Remind your patients that Case Management is not part of the EDs focus, and ED doctors are not oriented to the management of long term care but rather to the management of the presenting acute/ emergent condition.

3. Non-Urgent Visits to the ED VHP’s recent study on ED utilization revealed that many visits could have been handled in an Urgent Care or Primary Care setting. Please remind your patients that: • Unnecessary ED visits can lead to overcrowding.

• VHP has a 24/7 Nurse Advice line that can be used for urgent and non-urgent concerns.

This phone number is located on their VHP Member ID card.

• Prescription refills may be done through telephone and online using their provider’s electronic medical record system.

• Simple post-surgical procedures like suture removal and dressing changes can be done in the clinic.

4. PCP’s Role in Transition of Care Primary Care Practitioners play an important role in the healthcare delivery system to achieve positive, patient-centered outcomes. Empowering your patients to take charge of their health and wellness may reduce future ED visits and readmissions. A routine PCP visit will benefit your patient and may help avoid preventable ED visits.

Please take some time to discuss any concerns brought to your attention during an office visit.

Perform a medication reconciliation during the office visit and provide your patients with written or electronic instructions if needed. Effective education, including an assessment of the patient’s understanding of the information provided, is critical.

5. Avoid Fragmentation of Care A strong doctor and patient relationship is necessary in order to achieve safe and quality care. Help avoid fragmented care that may lead to: • Delays and other mishaps in care; • Waste due to duplicated and unnecessary services; • Patient, family, and peer dissatisfaction; or • Gaps in care leading to poor outcomes.

VHP believes that if we work together as a team, we can improve the patient experience by delivering timely, safe, effective, patient-centered, and

coordinated care.

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2014 Provider appointment availability Survey Results

Valley Health Plan (VHP) completed the 2014 Provider Appointment Availability Survey through a contracted service. The survey utilized the Department of Managed Health Care’s (DMHC) rigorous methodology and compliance rate calculation guidelines. Trained, professional interviewers conducted the survey by phone using a Computer-Assisted Telephone Interviewing (CATI) program to ensure all questions in the DMHC’s model appointment availability survey tool were asked without modification. The survey was completed in two waves, first one in October and then in December. Overall, a total of 374 providers were contacted. The DMHC’s specialty access services targets for this year were: Allergy, Cardiology, and Dermatology.

2014 Provider Appointment Availability Survey: Target Response Rate vs Actual Response Rate 100.0%

80.0%

60.0% Targeted response rate Actual response rate

40.0%

20.0%

0.0% Community Clinics

Independent Providers

Lucile Packard Children’s Hospital

Northen Cal Advantage Medical Group

Palo Alto Medical Foundation

San Jose Medical Group

Santa Clara Santa Clara Valley Medical County Individual Practice Center Association

Stanford Hospitals & Clinics

The table above represents the targeted response rate versus the actual response rate.

The results show access was being met for most of the timely access requirements, however, some of the services were below the VHP performance measure of 90% (orange line in each graph), as established by the VHP Quality Management Department. These results should be viewed with caution since a limitation to the survey findings is the time period in which the survey was conducted. It is likely that provider schedules may be different over the winter holiday season.

Non-Urgent Primary Care Physician (PCP) Visits within 10 Business Days

Compliance Rate

100.0% 80.0% 60.0% 40.0% 20.0% 0.0% Palo Alto Medical Foundation 6

San Jose Medical Group

Santa Clara Valley Medical Center

Non-Urgent Allergist Visits within 15 Business Days Compliance Rate

100.0% 80.0% 60.0% 40.0% 20.0% 0.0% Independent Providers

Lucile Packard Children’s Hospital

Palo Alto Medical Foundation

Non-Urgent Cardiologist Visits within 15 Business Days

Compliance Rate

100.0% 80.0% 60.0% 40.0% 20.0% 0.0% Northen Cal Palo Alto Medical Advantage Medical Foundation Group

Santa Clara Valley Medical Center

Stanford Hospital & Clinics

Non-Urgent Dermatologist Visits within 15 Business Days

Compliance Rate

100.0% 80.0% 60.0% 40.0% 20.0% 0.0% Lucile Packard Children’s Hospital

Northen Cal Advantage Medical Group

Palo Alto Medical Foundation

VHP is sharing this information with you as a reflection of how well we are doing together as a team. VHP would like to say thank you for all your work and effort toward meeting timely access regulatory standards and ensuring our Members receive the highest quality of care available.

VHP is committed to maintaining a strong partnership that has been established over many years with our community health practitioners and providers. You, as part of our growing community, have a voice and VHP wants to assure you that we are listening. Our goal is to collaborate in process improvement projects with you to ensure that our Member’s needs are met in a timely manner.

Thank you to those providers who participated in this survey, your feedback was very important.

San Jose Medical Group

Santa Clara Valley Medical Center

Stanford Hospitals & Clinics

It is understood that everyone’s time is valuable, however, we are asking that all providers participate in the 2015 survey. For this survey, the same services will be surveyed along with additional services DMHC has added. Additional services are: Specialist Physicians Psychiatrists (including Child & Adolescent Psychiatrists), Non-Physician Mental Health Practitioners (specifically PhD and Masters level), and Ancillary Appointments Physical Therapy, MRI, and Mammogram appointments.

VHP will be initiate the survey earlier in the year to ensure data collection is completed per DMHC guidelines.

If you have any questions regarding the call you receive from our contracted surveyor (EMC Research, Inc.), please feel free to contact Provider Relations at 408.885.2221.

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Disease Management and Complex Case

Management Programs

Did you know that you can refer qualified patients to the Valley Health Plan (VHP) Disease Management and Complex Case Management Programs? These programs are a benefit and a FREE service provided to eligible patients.

VHP has partnered with AxisPoint Health to co-administrate the VHP Disease Management and Complex Case Management Programs and work with Members to improve their health and quality of life. These programs consist of complex case management, care coordination, and preventive health education, including chronic disease selfmanagement. The programs are 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.

The Disease Management Program partners with you, the Members’ medical practitioner, 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’ (PCPs) 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 VHP has adopted the following clinical guidelines for practitioners’ use for diagnostic and treatment purposes: • Attention Deficit Hyperactivity Disorder (Children and Adolescents) • Coronary artery disease • Depression • Diabetes

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The Complex Case Management Program has AxisPoint Health 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 our members navigate the health care system along with encouraging adherence to their treatment plan and to decrease hospitalizations and unneeded use of emergency rooms. Members and caregivers may also self-refer to these programs. AxisPoint Health appreciates practitioner input on identifying eligible patients along with validating conditions identified, and care plan needs. All referrals can be made by calling 1.855.624.5223 (toll-free) or through a secure fax line at 1.800.542.8074. If you use a TTY, please call 1.800.735.2929 (toll-free) or your local telecommunication relay service.

Program Hours: Monday - Friday 8am - 8pm PST Saturday

8am - 12pm PST These programs were designed using current, nationally recognized evidence-based clinical guidelines. Please visit www.valleyhealthplan.org to review the clinical guidelines. If you would like paper copies of the clinical guideline summaries, please contact the program at 1.855.624.5223 (toll-free).

QUALITY MANAGEMENT HEDIS Quick Reference Guide What is HEDIS? Healthcare Effectiveness Data and Information Set (HEDIS) is a set of standardized performance measures developed by the National Committee for Quality Assurance (NCQA) which allows comparison across health plans. Through HEDIS, NCQA ensures that Valley Health Plan (VHP) is taking ownership and accountability for the timeliness and quality of care (acute, preventive, behavioral (mental) health, and other delivered to its diverse membership.

As you know, HEDIS 2015 contains 80 measures across five domains of care, which are as follows: • Effectiveness of care, i.e., immunizations, cancer screenings, diabetes care, weight assessment, appropriate treatment for acute and chronic illnesses, etc.

• Experience of care, measured by member satisfaction surveys

• Access/availability of care

• Health plan descriptive information

• Utilizations and relative resource use, i.e., frequency of selected procedures, well-child visits

Why is HEDIS Important?

As both State and Federal governments move toward a healthcare industry that is driven by quality, HEDIS rates are becoming more and more important, not only to the health plan, but to the individual practitioner as well. HEDIS reporting is mandated by NCQA for compliance and accreditation. It is important that health care practitioners and their staff members become familiar with HEDIS to understand what health plans are required to report. These measures are used to gauge the quality of care members receive and to identify areas for improvement.

How are Rates Calculated?

HEDIS rates can be calculated in two ways: administrative data or hybrid data.

• Administrative data consists of claim or encounter data submitted to the health plan. Measures that are typically calculated using administrative data include: annual mammogram, annual Chlamydia screening, annual Pap test, appropriate treatment of asthma, cholesterol management, antidepressant medication management, access to PCP services, and utilization of acute and mental health services.

• Hybrid data consists of both administrative data and a sample of medical record data. Hybrid data requires review of a random sample of Member medical records to abstract data for services rendered but were not reported to the health plan through claims/encounter data. Measures typically requiring medical record review include: comprehensive diabetes care, control of highblood pressure, immunizations, and prenatal care.

To ensure the validity of HEDIS results, all data elements are rigorously audited by certified auditors using a process designed by NCQA. Members benefit from HEDIS data through the State of Health Care Quality report, a comprehensive look at the performance of the nation’s health care system. HEDIS data is also the centerpiece of most health plan “report cards” that appear in national magazines and local newspapers.

How Can You Help Improve Our Rates?

VHP would like to reinforce the strong partnership with its practitioners and providers to promote awareness on the importance of HEDIS measures. You understand the value of screenings, regular office visits, and immunizations for our Members. Please remind Members the importance of getting the PREVENTIVE CARE they need and encourage regular office visits. Here are some suggestions for you: 1. Educate Patients Use your electronic health record to identify patients who haven’t been in recently.

Send them electronic or hard-copy materials about the importance of preventive health. As part of the patient education process, consider sharing success stories and how it impacted the patient’s way of life.

2. Offer Resources If patients are concerned about costs, make sure they understand that preventive check-ups are part of their covered benefit. If the patient tends to cancel often or a habitual no-show, find out why and work together to find ways they can make it to their appointment.

(Continued on pg.10) 9

3. Submit Accurate and Timely Claims/Encounter Data This will help reduce the number of medical record reviews required for HEDIS rate calculation. If services are not billed accurately, they have the tendency to be excluded in the calculation and skew the data.

4. Notify/Remind Members Simply remind Members while they are at your office to schedule their screening appointments or lab tests as appropriate.

5. Improve Member Experience We know that you are committed toward improving the Member care experience and VHP believes that we cannot achieve our goal unless patients have access to timely care and are satisfied with the care they receive. A positive member experience is optimal in achieving positive health outcomes.

6. Reinforce Communication Strategies Communication is pivotal to our success. Collaboration between Members of the health care team is beneficial to the Member as well as the team players.

7. Maintain Clarity of the Health Records Keep your records accurate, legible, and complete to facilitate good record review. Please use correct diagnosis and procedure codes to ensure accurate data capture.

How Can Valley Health Plan Help You? The results provided are just a small fraction of VHP’s HEDIS Rates. You, as the Member’s health care practitioner, play a central role in promoting health and wellness. VHP would like you to know that there are resources available to you. Please visit www. ncqa.org for more information about HEDIS. How Are We Doing?

HEDIS helps us to focus on problem areas and identify potential gaps in the system. Ultimately, a high HEDIS score means that our members are actively engaged in their health care and receiving the care they need. Please take some time to review the following HEDIS scores: HEDIS 2014

5Oth Percentile Quality Compass® National Average

Appropriate Treatment for Children with Upper Respiratory Infection

96.84%

85.47%

Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

23.40%

21.22%

Use of Appropriate Medications for People with Asthma - Total

91.96%

91.36%

Disease Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

85.96%

88.63%

Breast Cancer Screening

55.75%

70.15%

Cervical Cancer Screening

66.42%

75.68%

Colorectal Cancer Screening

57.42%

64.15%

43.76%

64.34%

Chlamydia Screening in Women - Total

51.83%

43.58%

Prenatal and Postpartum Care - Timeliness of Prenatal Care

88.71%

91.79%

Prenatal and Postpartum Care - Postpartum Care

72.58%

82.24%

CATEGORY/MEASURE MEDICATION MONITORING

SCREENINGS

IMMUNIZATION STATUS Immunizations for Adolescents - Combination PRENATAL AND POSTPARTUM CARE

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HEDIS 2014

5Oth Percentile Quality Compass® National Average

61.56%

63.00%

57.80%

60.98%

83.79%

88.78%

Comprehensive Diabetes - HbA1c Testing

89.78%

90.54%

Comprehensive Diabetes - LDL Screening

84.67%

85.68%

Comprehensive Diabetes - Medical Attention for Nephropathy

83.70%

84.40%

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)

26.52% 67.15% 45.31% 46.23% 66.91%

26.84% 62.63% 44.10% 48.58% 67.23%

6.48%

13.63%

33.33%

38.60%

64.64%

68.88%

46.39%

52.69%

85.40%

69.12%

CATEGORY/MEASURE 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 DIABETES MANAGEMENT

ALCOHOL & OTHER DRUG MONITORING Initiation & Engagement of Alcohol & Other Drug Dependence Treatment – Engagement Total (Continued from pg. 9) 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 VHP encourages Members to take advantage of important preventive care services.

HEDIS 2014

5Oth Percentile Quality Compass® National Average

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

86.21%

81.34%

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

80.75%

74.82%

Adolescent Well-Care Visits

42.09%

41.91%

CATEGORY/MEASURE

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vhp Listens Valley Health Plan (VHP) is committed to maintaining a positive relationship with our practitioners. In the spring of 2015, EMC Research Inc. conducted its annual satisfaction survey with VHP practitioners. These survey results help us understand what practitioners think about our overall performance, where we can improve, and what areas are well managed. Your input is valuable to us and helps identify areas for improvement.

Some Positive Comments Received This Year: “VHP is well organized. Physician/ provider friendly and easy to access.”

“Pretty good and timely care if going through PAMF for my VHP patient.”

“Have referred to brain rehab. They do good work.”

“Keep doing the good work! Thanks.”

In 2014, VHP reached out to our practitioners with the goal of improving the exchange of information between primary care and behavioral health practitioners. This performance improvement initiative was a direct result of the concerns many of our practitioners voiced during the satisfaction survey that year. Although the most recent survey did not indicate a decrease in these concerns related to the coordination of care, there was a slight improvement in the coordination of care between medical and specialty services.

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The VHP Authorization for Use and/ or Disclosure of Protected Health Information Form authorizes the release of information between practitioners, whether medical or behavioral health and is available at www.valleyhealthplan.org under the Provider > Forms and Resources > Forms. VHP will continue to look for innovative ways of improving this exchange of information and will continue the educational campaign to both members and practitioners.

Thank you for your participation in the 2015 satisfaction survey. VHP is always interested in your ideas on how to improve communication between practitioners with the ultimate goal of improving the coordination of care for our Members. If you have any ideas you would like to share with us, please contact the Providers Relations Department at 408.885.2221.

QNXT & icd-10

Updates

Valley Health Plan (VHP) is currently migrating from our Diamond legacy claims processing system into our next generation claims system, QNXT set to go-live on October 1, 2015.

837 Changes Required As part of this migration, those currently submitting 837’s will be required to make minor changes to their submissions. VHP will send out a detailed communication to those currently submitting 837’s and request assistance in testing.

Pathologists and Physical Therapists Currently in our Diamond legacy system, both Pathologists and Physical Therapists bill under the Group NPI, however effective October 1, 2015, you will be required to bill under the Rendering NPI in QNXT. Respiratory, Occupational, and Speech/ Hearing Therapists Currently in our Diamond legacy system, these Respiratory, Occupational, and Speech/Hearing therapists bill under the Rendering NPI, however effective October 1, 2015, you will be required to bill under the Group NPI.

ImmuniZation benefits & services

Update

Valley Health Plan (VHP) encourages Members to get required immunizations as recommended by the U.S. Preventive Services Task Force to help keep them healthy. VHP coverage includes immunizations provided by Primary Care Practitioners (PCPs) or through VHP Plan Pharmacies where immunization services are available.

Travel immunizations are covered only when received at a VHP Plan Pharmacy or through their PCP. (*Please note that travel immunizations received from the Santa Clara County Public Health Travel Clinic at Lenzen are no longer covered by VHP.) Travel immunization consultations are not a covered benefit. For travel immunization information, please visit www.cdc.gov under Travelers’ Health.

Please refer your VHP patients to our website at www.valleyhealthplan.org to find a Plan Pharmacy.

For additional information, they can call VHP Member Services at 1.888.421.8444 (toll-free).

ICD-10 Coming Soon Effective October 1, 2015, all health care providers are required to utilize ICD-10. VHP has been working hard to ensure compliance with this regulation. The QNXT go-live date is strategically aligned with the CMS ICD-10 deadline.

All current open authorizations will not have to be re-entered; however, any authorization requests received after September 30, 2015 must contain ICD-10 codes. If the Member no longer needs the authorization, no further action will be required.

For 837 submissions, trading partners will be required split their 837 claims into two groups, those before a Date of Service of October 1, 2015 and those claims with a Date of Service after October 1, 2015. VHP will send out a detailed communication to those currently submitting 837’s and request assistance in testing.

Thank you in advance for your assistance. VHP is very excited about the new system as it will ensure greater efficiency and coordination within the Plan.

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my cerner Wellness For many of your patients, it may be difficult to live a healthy lifestyle. Valley Health Plan (VHP) has partnered with Cerner Wellness to provide Members with free resources and support to assist them in living a healthier life. You can also partner with VHP by talking to your patients about this free program.

You can direct your patients to the VHP Wellness Portal “My Cerner Wellness� at https://vhp.mycernerwellness.com or they can access this information at www.valleyhealthplan.org > Health & Wellness > Personal Health Assessment.

Benefits By using this online health management program, your VHP patients can be more engaged and are encouraged to make healthier choices in their behaviors, potentially reducing medical costs. Once your VHP patient creates an account, they will have access to a Personal Health Assessment (PHA). The PHA is an easy way to help them identify health risks in all aspects of their life. There are also recommended online tools and resources based on the health risks identified. Other perks for users are meal plans based on specific needs, chat functions with nutritionists and personal trainers, an online health library, healthy recipes, food logs, exercise tips, symptom checker, online workshops, and a monthly newsletter.

Rewards VHP Members who use My Cerner Wellness can earn wellness points by completing a variety of activities on the wellness portal for four (4) levels of rewards. Some examples of ways to earn rewards are tracking labs and health markers, logging steps/physical activity, and even using a food journal. There are also health and wellness workshops and programs available.

Why Refer Your Patient?

By referring your VHP patients to My Cerner Wellness, you are helping to provide VHP, yourself, and other providers with valuable data that could help with increased planning and communication, incentives campaigns, health education seminars/workshop/webinars and reporting services. By being able to identify the high risks and needs of your patients, our Members, you will be able to help them better manage their health.

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Pharmacy Corner

VHP Drug Formulary The 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 P&T Committee decisions include adding drugs to the Formulary, requiring prior authorization for some drugs, requiring quantity limits or step therapy, the process for generic substitution, therapeutic interchange, or not adding the drug to the Formulary. These decisions are based on US Food and Drug Administration (FDA) approval, scientific articles, drug safety, and whether there are other like drugs available that accomplish the similar results.

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

After each P&T Committee meeting or at any time, you can visit www.valleyhealthplan.org to view the drug Formulary and Formulary summary of updates. If you do not have access to the Internet and would like a paper copy of the VHP drug Formulary, please contact Navitus Customer Care at 1.866.333.2757 (toll-free), visit www.valleyhealthplan.org, or call VHP Provider Relations at 1.408.885.2221, option 2.

Please refer to the VHP Provider Manual at www.valleyhealthplan.org for information about the VHP P&T Committee.

Navitus Health Solutions Navitus Health Solutions is VHP’s Pharmacy Benefit Manager (PBM). Navitus Health Solutions administers the pharmacy benefit on behalf of VHP, including customer service, Formulary maintenance, Prior Authorizations, Exception to Coverage, and drug recall notifications. Navitus Customer Care is available 24/7, except Thanksgiving Day and Christmas Day, at 1.866.333.2757 (toll-free).

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Provider Relations

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

© 2015 Valley Health Plan

VHP CHIEF MEDICAL OFFICER Dolly C. Goel, MD VHP MEDICAL ADVISORS Stephen Harris, MD Michael Meade, MD Gary Steinke, MD BOARD OF SUPERVISORS Cindy Chavez Dave Cortese S. Joseph Simitian Mike Wasserman Ken Yeager COUNTY EXECUTIVE Jeffrey V. Smith