Provider Bulletin Winter Spring 2017

Bulletin Profile Information

VHP is committed to providing our Members with the most accurate and current provider network information available. In compliance with Health and Safety Code Section 1367.27 as enacted

by Senate Bill 137 (2015), providers and medical groups will be asked annually to verify contact and provider profile information represented in the VHP Provider Directory. Individually contracted providers will be asked to verify contact and provider profile information bi-annually. To meet this new regulatory requirement, VHP will send out a notification requesting providers respond to affirm their profile information is current.

Information can be verified or updated at: www.valleyhealthplan.org/sites/providers/Pages/ provider-directory-change-form.aspx Members can report potential directory data inaccuracies to VHP Member Services Department at 1.888.421.8444 (toll-free) and to the Department of Managed Health Care Help Center at 1.888.466.2217 (toll-free).

Thank you for your assistance providing our Members with the information needed to access quality health care services in the VHP network.

VOLUME 20 | WINTER - SPRING 2017

PROVIDER

PROVIDER DIRECTORY

TABLE OF CONTENTS Provider Directory Profile Information................................ 1 Disease Management and Complex Case Management Programs.................................. 2 Attention-Deficit / Hyperactivity Disorder (ADHD)....................... 3 Medication Adherence for Members with Depression........ 4 Choose Health, Live Well.......... 6 Timely Access.......................... 8

Management of Chronic Pain....10 HEDIS Quick Reference Guide...................................... 12 Provider Resources and Information.............................. 14 Clearinghouse Updates for 835 Providers......................... 15 277 Claims Acknowledgement Reports................................... 15 Topical Flouride Varnish......... 15

DISEASE MANAGEMENT AND COMPLEX CASE

Management Programs

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 self-management. 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 • Coronary Artery Disease

• Depression • Diabetes • Heart Failure

• Schizophrenia • Chronic Obstructive Pulmonary Disease (COPD)

VHP has adopted clinical guidelines for practitioners’ use for diagnostic and treatment purposes: • Attention Deficit Hyperactivity Disorder (Children and Adolescents) • Coronary artery disease

• Depression • Diabetes

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).

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ATTENTION-DEFICIT / HYPERACTIVITY DISORDER (ADHD) Quality Care That You Deserve

This article was published in the VHP Member Newsletter, Perspectives, encouraging members to make an appointment with their prescribing provider within 30 days of starting a new medication for ADHD. Attention-deficit/hyperactivity disorder (ADHD) is a common neurobehavioral disorder in children which can significantly impact school academics, socialization, and over all well-being of the child as noted by the American Academy of Pediatrics1. This disorder affects 5 to 8 percent of school age children2. ADHD is usually diagnosed in early childhood and can last throughout adulthood.

Early diagnosis and appropriate treatment is important because without the identification of the condition and implementation of an appropriate doctor lead treatment plan, this condition can impact an individual’s entire life, which could lead to school failure, school dropout, depression, challenges with relationships including failed relationships, substance abuse, and underachievement in the workplace environment3.

Appropriate treatment may help an individual lead a productive and satisfying life.

Visit the Centers for Disease Control and Prevention (CDC) ADHD website for information about signs, symptoms, causes, diagnosis, and treatment at www.cdc.gov/ncbddd/adhd/facts.html

Signs and Symptoms: People may daydream a lot, forget or lose things often, squirm or fidget, talk too much, make careless mistakes or take unnecessary risks, have a hard time resisting temptation, have trouble taking turns, and have difficulty getting along with others.

Diagnosis: The diagnosis of ADHD is not done by any single assessment. It is a multi-faceted process which takes into consideration the information from parents, teachers, and at times, the child.

Treatment: In some cases, ADHD may be treated with a combination of behavioral therapy and medication. Unfortunately, there is no single treatment that is effective for every person and a good treatment plan will include close monitoring, follow-ups, and adapt to needed changes. ADHD medications can be an important part of the treatment plan, which can help manage symptoms effectively.

Follow-Up Visit(s): Valley Health Plan’s (VHP) mission is to ensure that you receive quality care and service at the right time, right place, and by the right provider. VHP believes it is important for members who are newly diagnosed and prescribed ADHD medication to have a face-to-face follow-up visit with the prescribing doctor at a minimum of within 30 days of the new prescription, especially those 6 to 12 years of age. The 30 days following the initiation of the ADHD medication is a critical phase as this is the stage where the medication regimen could be fine-tuned.

A person’s response to medications used to treat ADHD can vary, ranging from minor to serious. In addition, some medications work better than others. VHP encourages you to schedule a follow-up appointment with the member’s doctor when prescribed an ADHD medicine to discuss any issues or concerns. Keeping your follow-up appointment is key, so be sure to mark your calendar. Once the doctor determines the person is stable on the medication, visits may be spaced out.

Speak Up: Your doctor is there to help. Don’t be afraid to ask them any questions you may have about any new medications. A follow-up visit provides an opportunity to closely monitor side effects, adverse reactions, or any unusual circumstances. This is also an opportunity for you to discuss how the individualized behavioral treatment plan is working for you and your family.

Remember to ask questions and be an active member of the care team. Know that a positive outcome may depend on a strong partnership between patients, families, and their doctors. Keep your follow-up appointment within 30 days of new prescription!

1. American Academy of Pediatrics – From the American academy of Pediatrics Guidance for the Clinician in Rendering Pediatric Care. Pediatrics Volume 128, Number 5, November 2011.

2. National Resource Center on ADHD – A Program of CHADD. Managing Medication for Children and Adolescents with ADHD (What We Know – Sheet 3).

3. National Resource Center on ADHD – A Program of CHADD. Managing Medication for Children and Adolescents with ADHD (What We Know – Sheet 3).

www.valleyhealthplan.com 3

MEDICATION ADHERENCE for Members with Depression Continuity and coordination of care between Primary Care Physicians (PCP) and behavioral health providers is crucial to the comprehensive treatment and well-being of our members.

VHP’s hope is that our practitioners will: 1. Continue to foster and/or enhance member participation in their planned care; 2. Ensure that the member has a clear understanding of why picking up and taking their prescribed medication is an important part of the treatment plan; 3. Help the member understand how the medication can benefit them and that it may take time to work; and 4. Explain the possible side effects they may experience and how they can cope with it.

Continuity and Coordination of Care VHP wants our Members to receive the best health care possible by encouraging continuity and coordination of care between health care professionals. The goal of coordinated care is to make sure that the member receives the right care at the right time, avoiding unnecessary duplication of services and preventing medical errors. One of the most important steps as the patient’s doctor that you can take is being aware of all the health care services the patient is receiving from other doctors or health care professionals. This includes obstetricians and gynecologists (OB/GYNs), family planning providers, dentists, behavioral health providers such as psychiatrists, psychologists and counselors, chiropractors, and eye doctors. One way you can help with coordination of care is by talking to your patient about the importance of sharing their health information and obtaining consent through the use of the Authorization for Use and/ Disclosure of Protected Health Information Form. This form can be located on the VHP website at www. valleyhealthplan.org under Member Materials > Forms & Resources.

Also encourage your patients to discuss other information that has been given to them from other healthcare professionals, including medications they are taking that you should be aware of. The sharing of health information ensures that you as a physician, as well as other health care providers, have all the important information about the member’s health history which helps you understand the patient’s physical and emotional health needs, providing comprehensive coordination of care and improved health outcomes.

The information listed below has been shared with our member’s in their recent newsletter and we wanted you be aware of this information.

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Treating Depression Everyone feels sad once in a while. Usually these feelings pass in a few days, but if you feel sad or down for days at time, see your doctor. Seek help immediately if you feel hopeless, are thinking about suicide, or turn to alcohol or drugs for relief. If you are experiencing depression, you can get better with the proper medical care. You may need medical treatment with medication and/or counseling or you may only need treatment to get past the feelings of depression. If you have questions about the treatment plan, talk to your doctor and/or counselor.

Some common thoughts you may have: a. “I do not need or want medication and I do not want to pick up my prescription.”

It is always important to be a part of the decision on what prescription you may need to take, please speak with your doctor about the medication they are prescribing. When you play a part in this important decision, you will better understand the importance of picking up and taking your medication. b. “I am feeling better and do not need any more medication.”

Feeling better is great news, and it may be the right time to stop your treatment, however, it is important to ask your doctor how long to continue taking your medication and be sure that you both agree on the treatment plan. Sudden stopping of your medications could result in a return of your depression or withdrawal symptoms such as dizziness, sleeping problems, and anxiety. It is important for you and your doctor to work together to determine when it is right for you to stop or start reducing your medication. c. “I do not like the side effects of the medication.”

If the side effects are bothering you, let your doctor know. Explain what you are experiencing so your doctor can adjust or change your medication or treatment. You may also find that some side effects will get better with time, your doctor can tell you about this for the medication prescribed to you. d. “This medication is not working.”

Make sure you give the medication enough time to work. Some medications can take several weeks or longer before you start feeling much better. If a medication does not work for you, let your doctor know.

You and your doctor can work together and discuss whether to change the medication. You can also talk to your doctor about counseling, “talk therapy”. Along with taking the medication, adding counseling can be very effective.

Once you and your doctor figure out the right treatment plan for you, you will be well on your way to feeling good again. Here are some easy tips to help you manage your medicines: 1. Be a participant with your doctor on your treatment plan, which includes your medications.

2. Please pick up your medication.

3. When picking up your medication, if you have questions – ask the pharmacist. You can also talk to your doctor.

4. Read all the information about your medication before you take it.

5. Always keep enough of your medication on hand; get refills before you run out of your medication.

6. Develop a schedule for taking your medication and stick to it.

7. Remind yourself by setting an alert on your cellphone or other electronic device, sending yourself an email or text, writing a note, creating a checklist, or some other type of self-reminder.

8. Develop a supportive network of your family and friends. www.valleyhealthplan.com 5

CHOOSE HEALTH, Live Well The VHP Health Education Department supports members with education, classes, and a free online wellness portal. This easy 15-minute Personal Health Assessment (PHA) will help your patients understand their current health status. Have your patients visit vhp.mycernerwellness.com to start earning wellness points for rewards and to: • Get their personalized PHA results and wellness recommendations; • Sync their Fitbit® and mobile app to conveniently track their exercise and fitness; • Access exercise video clips and online health education workshops; • Track their daily food and water intake; • Chat with certified personal trainers and registered dietitians about their health questions; • Try healthy recipes and specialized meal plans to keep them motivated; and • Access an extended library of resources and various health topics.

VHP members can contact the Health Education Department at healtheducation@vhp.sccgov.org or 408.885.3490 for more information.

New Diabetes Prevention Program Are your patients pre-diabetic or have borderline diabetes? Do they have high blood sugar? Have they had gestational diabetes? Do they have a family history of diabetes?

There is good news! VHP is partnering with the YMCA to offer a FREE 16-week Diabetes Prevention Program that includes a YMCA membership. The YMCA’s Diabetes Prevention Program can help your patients make lifestyle changes to improve their overall health & well-being, while lowering their disease risk. Have your patient enroll today! Change is tough – we can help.

VHP members can contact the YMCA Diabetes Prevention Program at ymcadpp@ymcasv.org or 408.351.6440 or visit www.ymca.net/diabetes-prevention to learn more.

VHP Cares About Health & Well-Being It is important for your patients to know about common preventive screenings that are available to them, to take care of themselves and their family. Visit www.valleyhealthplan.org > Member Materials > Forms & Resources to find the recommended preventive health guidelines for screenings and immunizations.

Breast Cancer Screening Look for VHP’s Breast Cancer Awareness Campaign in 2017 encouraging a dialog between providers and patients about breast cancer and the importance of screenings.

• Fact: 1 in 8 women will be diagnosed with breast cancer in their lifetime.

• Good News: If breast cancer is detected early, it can be treated.

• Good News: Breast cancer prevention screenings are free! VHP covers the cost of a breast exam and mammogram.

Cervical Cancer Screening • Fact: Regular screening decreases cancer of the cervix by at least 80%.

• Good News: Cervical cancer can usually be treated if it is found and treated in the early stages.

• Good News: Cervical cancer screening is free! VHP covers the cost of the cervical screening test.

There are two tests that can help prevent or find cervical cancer early.

1. Pap Test or Pap Smear: This test can find certain cells which can be removed before you develop cervical cancer. This test can also find cervical cancer at an early stage.

2. HPV Test: If you are 30 years or older, you may choose to get the human papillomavirus (HPV) test along with your Pap Smear. This test looks for a cancer causing virus that can damage your cells.

6 Provider Bulletin | Winter - Spring 2017

Chlamydia Testing • Fact: Chlamydia affects nearly 3 million Americans each year of which most are women under the age of 25. Nearly 1 in 10 teenage girls tested for chlamydia tested positive and approximately 75% of women with chlamydia did not realize they were infected.

• Good News: Chlamydia is painless to treat.

• Good News: Chlamydia screening tests are free if you are under 25 years of age. VHP covers the cost of the test under the age of 25, as well as women older than 25 in some cases.

Early Childhood Immuzinations Immunizations protect your patients from getting preventable diseases.

According to the World Health Organization, in 2014 there were 114,900 deaths from measles globally about 314 deaths every day or 13 deaths every hour. There were even a number of preventable cases of pertussis (Whooping Cough) and measles recently in California.

During visits, be sure that your patients are up to date on recommended vaccines. For adolescent patients who may have missed any recommended vaccines, have a discussion with the parent/guardian about a catch-up schedule to help prevent the risk of infections. It is important to educate the parent/guardian of the importance of vaccination in case they have any concerns or are avoiding vaccinations.

Visit www.valleyhealthplan.org > Member Materials > Forms & Resources to find the recommended preventive health guidelines for screenings and immunizations.

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TIMELY ACCESS

How Much Time Should it Take to Access Health Care Services?

VHP would like to keep you informed of the important facts regarding the California Timely Access Standards. The California Department of Managed Health Care (DMHC) requires health plan members to be seen in a timely manner. The primary intent of these regulations and the underlying legislation is to ensure that the VHP network of providers have the capacity and availability to provide care to you within certain timeframes for the various levels of care. However, sometimes waiting longer for care is not a problem. Your Physician may give you a longer wait time if it would not be harmful or your health.

It must be noted in your record that a longer wait time will not be harmful to your health.

Please take time to read the following California Timely Access Standards.

APPOINTMENT SCHEDULING

WAITING TIME

Emergency services

Immediately

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

48 hours of request

Urgent Care appointments that require prior authorization

96 hours of request

Non-urgent appointments for PCP

10 business days of request

Non-urgent appointments with Specialty Care Physicians (SCP) including Obstetrical Care

15 business days of request

Non-urgent appointments for Ancillary Services (for diagnosis or treatment of injury, illness, or other health condition)

15 business days of request

Office/Clinic Wait Time (From appointment registration time to when seen by the practitioner/doctor.)

30 minutes (VHP Standard)

AVAILABILITY OF BEHAVIORAL HEALTH CARE PRACTITIONERS

WAITING TIME

Life threatening emergency

Immediately

Non-life threatening emergency Urgent Care appointments

6 hours 48 hours of request

Non-urgent appointments with Psychiatrists

10 business days

Non-urgent appointments with a non-physician Behavioral Health Care Practitioner (Psychologist, MFT, LCSW) and Psychiatrist

10 business days

Office/Clinic Wait Time AFTER-HOURS CARE 24/7 Nurse Advice Line

8 Provider Bulletin | Winter - Spring 2017

VHP has a standard of 30 minutes maximum (The time from appointment registration until you see the practitioner/doctor) AVAILABILITY Employer Group Members: Call 1.866.682.9492 (toll-free) including holidays and weekends.

Covered California and Individual & Family Plan Members: Call 1.855.348.9119 (toll-free) including 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.

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.

www.valleyhealthplan.com 9

MANAGEMENT of Chronic Pain VHP is committed to play its role in helping curb the opioid overuse and opioid overdose epidemic for our members. The US Centers for Disease Control and Prevention (CDC) declared the overuse of opioid medications an epidemic in 2011. Deaths from opioid overdose increased steadily over the last two decades, nearly quadrupling between 1999 and 2013.1 Drug overdose-related deaths now exceed deaths from motor vehicles and firearms in the United States. Prescription opioid overdose deaths exceed those from cocaine and heroin combined.2 Hospital admissions for opioid addiction treatment have increased fivefold,3 as have related medical complications such as nonfatal overdoses, falls and fractures, drug-drug interactions, fatal heart rhythm disturbances, and neonatal abstinence syndrome, which often require prolonged stays in intensive care.4 In 2013, the Centers for Medicare and Medicaid Services (CMS) introduced Medicare Part D plan’s opioid overuse initiative to address opioid overutilization.

From 2011 through 2015, Part D sponsors saw a 47% decrease in Part D beneficiaries identified as potential opioid overutilizers (i.e., beneficiaries with at least 90 consecutive days with greater than 120 mg MED daily with more than three prescribers and more than three pharmacies contributing to their opioid claims), from 29,404 to 15,651.5 In 2016, the California Health Care Foundation (CHCF) put out two reports summarizing effective opioid utilization control measures health plans across California implemented to fight the opioid epidemic, improve the health of their plan members while maintaining medication access.

Current VHP drug utilization review (DUR) opioid utilization controls: 1. Retrospective DUR (RDUR) Program identifies members based on preset safety criteria and notifies prescriber of potential safety concerns including potential for controlled substance overuse, abuse and dependence.

- Controlled Substance Monitoring (CSM) Program identifies member’s potential overuse of controlled medications (schedules II through V). The profiles identified patients with 9 or more prescribers, pharmacies and prescriptions for controlled medications during the last four months.

2. Concurrent DUR (CDUR) Program aids pharmacists in protecting member health and safety by ensuring patients receive the appropriate medications through hard and soft electronic rejects - Morphine Equivalent Dose (MED) alert identifies at point-of-sale (POS) members with MED greater than 120 mg, more than two pharmacies and more than two doctors for active opioid claims 3. Covered Non-Pharmacologic Pain Management Options - Fitness and relaxation technique classes through VHP Health Education 408.885.3490 - Mental Health Services/Outpatient Mental Health & Behavioral Health Treatment Counseling Services - visit www.valleyhealthplan.org for a list of providers - Chemical Dependency Services (Alcoholism and Drug Abuse) Gateway Program 1.800.488.9919 - Acupuncture – visit www.valleyhealthplan.org for a list of providers - Chiropractic services – visit www.valleyhealthplan.org for a list of providers - Physical Therapy – visit www.valleyhealthplan.org for a list of providers

10 Provider Bulletin | Winter - Spring 2017

In 2016, the VHP Pharmacy & Therapeutics Committee implemented the following opioid utilization controls to VHP formularies. Please check the appropriate VHP Formulary for your patient’s drug coverage.

1. Formulary Removals a. Nucynta (alternatives include hydrocodone, oxycodone, hydromorphone and morphine) b. Oxycodone IR CAPSULES (alternative: oxycodone IR tablets) c. Promethazine w/codeine syrup (alternative: guaifenesin w/codeine) d. Carisoprodol (SOMA equiv) tablets (removed from formulary d/t high abuse, dependence issue and current utilizers GF for lifetime; prescribers sent informational notification letter) 2. Formulary Additions – non-opioid pharmacologic pain treatment options a. Duloxetine (Cymbalta equiv) capsules (added to Covered California formulary with QL 2 caps/day to mirror Employer Group formulary) b. Narcan (added with QL 2 sprays/fill) c. Lyrica (pregabalin) capsules and solution (added to Covered California formulary to mirror Employer Group formulary) d. Lidocaine 5% (Lidoderm) transdermal patches (add all LOBs T1/T3 with QL max 3 patches/day) 3. Utilization Management (UM) Edits a. Naloxone inj – allow quantity limit (QL) of 2 vials/fill b. Guaifenesin w/codeine syrup – prescribing quantity limit restricted to 120 ml/fill 4. MED POS Trigger Criteria a. Revised criteria: MED greater than 90 mg and more than 2 Prescribers In conclusion, the opioid epidemic is a complex challenge for providers, health plans, and public health institutions alike. We all need to work together to innovate, share and adopt effective strategies to curb the epidemic and change the opioid prescribing culture. VHP is committed to support judicious opioid prescribing practices with formulary changes based on clinical guidelines and best practices. At the same time, we want to address the needs of populations already harmed by opioids with case management, coverage for non-opioid pain treatments and psychosocial support.

1. Li-Hui Chen, Holly Hedegaard, and Margaret Warner, “QuickStats: Rates of Death from Drug Poisoning and Drug Poisoning Involving Opioid Analgesics – United States, 1999-2013,” Morbidity and Mortality Weekly Report 64, no. 1 (January 16, 2015): 32, www.cdc.gov.

2. 2015 National Drug Threat Assessment Summary, US Drug Enforcement Administration (2015), www.dea.gov 3. L.J. Paulozzi et al., “Vital Signs: Overdoses of Prescription Opioid Pain Relievers – United States, 1999-2008,” Morbidity and Mortality Weekly Report 60, no. 43 (November 4, 2011): 1487-92, www.cdc.gov 4. The Prescription Opioid Epidemic: An Evidence-Based Approach, Johns Hopkins Bloomberg School of Public Health (November 2015), www.jhsph.edu 5. An excerpt from the CMS Final 2017 Call Letter, Improving Drug Utilization Controls in Part D – Results of Overutilization Policy (www. cms.gov/Medicare/Prescription-DrugCoverage/PrescriptionDrugCovContra/RxUtilization.html).

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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 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 followed: • Effectiveness of care, i.e., immunizations, cancer screenings, diabetes care, weight assessment, appropriate treatment for acute and chronic illnesses, etc.; • Access/availability of care; • Experience of care, measured by member satisfaction surveys; • Utilizations and relative resource use, i.e., frequency of selected procedures, well-child visits; and • Health plan descriptive information.

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 provider as well. HEDIS reporting is mandated by NCQA for compliance and accreditation. It is important that health care providers 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 our members receive and to identify areas for improvement.

How rates are 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. While hybrid data consists of both administrative data and a sample of medical record data. Hybrid data requires a review of a random sample of member medical records to abstract data for services rendered but that were not reported to the health plan through claims/encounter data. Measures typically requiring medical record review include: comprehensive diabetes care, control of high-blood 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. Health plan 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 are we doing?

HEDIS helps us zone in on problem areas and identify potential gaps in member care. Ultimately, high HEDIS scores mean that members are actively engaged in their care and receiving the care they need.

For the 2016 HEDIS season, VHP did very well on several measures: • HGB Testing • Neuropathy • Human Papillomavirus Vaccine for Female Adolescents • Initiation and Engagement of Alcohol and Other Drug Dependence Treatment 12 Provider Bulletin | Winter - Spring 2017

• Use of Imaging Studies for Low Back Pain • Appropriate Treatment for Children with Upper Respiratory Infection • BMI Percentile for Children • Counseling for Nutrition for Children

We THANK YOU for your high quality of care you provide to our members and for thoroughly documenting the care provided. This documentation rightfully confirms the excellent care you provide.

However, there is room for improvement on some measures: • Asthma Medication Management and Ratio • Appropriate Testing for Pharyngitis • Cervical Cancer Screening

• Post-Partum Care • Colorectal Screening

VHP recognizes it is important for providers to receive information from VHP to assist them in identifying members who may be in need of care and testing. In 2017, VHP plans to roll out a program where information will be given to providers identifying members who are in need of care. We have been working with our HEDIS vendor and refining software called Care Gap Finder. VHP is in the process of validating information in Care Gap Finder Reports and testing. We welcome your feedback on rollout of these reports. If you would like to be involved by providing suggestions or participating in our testing, please call 408.885.5924 for more information.

If you would like training on HEDIS in general or best documentation practices to get credit for HEDIS measures, please let us know by calling VHP Provider Relations at 408.885.2221 to request training.

Working together to improve HEDIS rates Valley Health Plan would like to reinforce the strong partnership with its practitioners and providers to promote awareness on the importance of HEDIS measures. You know the value of screenings, regular office visits and immunizations for our members. Please remind them of 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 (HealthLink) to identify patients who haven’t been in recently. Then, 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 a patient tends to cancel often or is a habitual no-show, find out why and recommend ways to help them make it to their appointment.

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’s 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 record accurate, legible, and complete to facilitate good record review. Use of correct diagnosis and procedure codes.

VHP appreciates the pressures and effort of providing high quality health care to our members and value the hard work demonstrated by providers. We look forward to continued success and growing our partnership in 2017. www.valleyhealthplan.com 13

PROVIDER RESOURCES AND INFORMATION

Valley Health Plan Website

Visit www.valleyhealthplan.org/sites/p/Pages/Providers.aspx for resources and information that you can view and/or download, including: • The process to refer members to case management.

• The process to refer members to disease management.

• Information about disease management programs, including how to use the services and how VHP works with a practitioner’s patients in the program.

• Information about VHP’s medical necessity criteria, including how to obtain or view a copy.

• Information about the availability of staff to answer questions about UM issues.

• The toll-free number to contact staff regarding UM issues.

• VHP’s policy prohibiting financial incentives for utilization management decision-makers.

• Information about VHP’s pharmaceutical management procedures including our drug list along with restrictions and preferences; how to use pharmaceutical management procedures; an explanation of limits and quotas; how practitioners can provide information to support an exception request; and VHP’s processes for generic substitution, therapeutic interchange, and step-therapy.

• A description of the process to review information submitted to support a practitioner’s credentialing application, correct erroneous information and, upon request, to be informed of the status of the credentialing or recredentialing application.

• VHP’s Member Rights and Responsibilities.

For questions or for more information, please call the Provider Relations Department at 408.885.2221.

14 Provider Bulletin | Winter - Spring 2017

CLEARINGHOUSE UPDATE FOR 835 PROVIDERS with Utah Health Information Network (UHIN)

UHIN is now the exclusive connection point for receiving all claims and reports. VHP chose UHIN because of their reputation for excellent customer service and ability to streamline the claims process.

VHP is excited to offer you 835 Claim Payment/Remittance information. You will receive your 835s electronically direct from your clearinghouse. This means you will save time by no longer having to log on to Change Healthcare to download and print a PDF version of the 835.

Depending on your clearinghouse, you may need to enroll for 835s. Contact your clearinghouse directly to see if you need to take any additional enrollment steps.

If you do not use a clearinghouse for claims submission, VHP can still work with you to receive an 835.

You may consider having UHIN become your direct clearinghouse. Contact UHIN at enrollment@uhin.org to find out more about this option.

If any issues with your current clearinghouse prevent you from getting your claims processed, contact UHIN Customer Service at customerservice@uhin.org or 1.877.693.3071 (toll-free).

COMING SOON!

277 Claims Acknowledgement (CA) Reports VHP will provide 277 CA status reports soon. You will now be receiving 277 CA reports from your clearinghouse. These acknowledgements will provide you with greater insight into the status of your claims.

277 CA reports allow you to save you time by: • Reducing calls to VHP to check your claim status • Understanding why a claim has been rejected • Correcting errors and resubmit your claim If you have any questions, please feel to contact your clearinghouse.

TOPICAL FLUORIDE VARNISH

Coverage for Medi-Cal Patients Under Age 6 Topical fluoride varnish is a covered medical benefit for Medi-Cal patients under age 6.

Fluoride varnish is a form of topical fluoride that prevents tooth decay and is safe to use in young children.

Fluoride varnish can be swabbed directly on the teeth in less than three minutes and sets within one minute of contact with saliva. The application requires no special dental equipment and can be applied with minimal training by physicians, nurses, and supervised medical assistants.

You can submit claims for this service by using HCPCS code D1203 for children younger than 6 years of age up to three times in a 12 month period.

Please see the link below for parent information sheets that are available in English, Spanish, Chinese and Korean languages. Additional information on dental care and fluoride varnish can be found at the following website: www.dhcs.ca.gov/services/chdp/Pages/CHDPDentalTraining.aspx www.valleyhealthplan.com 15

Provider Relations 2480 N. First Street, Suite 200 San José, CA 95131

© 2017 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