April 2016
General News
PCA and home health request forms added online
Medica has recently added two new personal care assistance (PCA) request forms as well as updated and moved a home care request form on medica.com. The PCA forms are required by the Minnesota Department of Human Services (DHS) for use with Minnesota Health Care Programs (MHCP) enrollees.
See the PCA request forms (fax completed forms to Medica Health Management at 952-992-3556):
- Referral for PCA Services form
- PCA Technical Change Request form
See the home care request form:
Saving the latest links, and updating any links that were previously bookmarked, allows quick access to current documents without interruption. Providers who have questions about the forms above may call the Medica Provider Service Center at 1-800-458-5512.
Reminder:
Practices asked to validate their demographic data soon
As mentioned last month, Medica is sending providers an annual data-validation request at the end of March. Responses are due by April 15, 2016. Data validation allows providers to verify the accuracy of their demographic information currently listed in the Medica database, applicable for all Medica products.
Medica is moving to real-time demographic updates as required by the Centers for Medicare and Medicaid Services (CMS). Due to this new CMS requirement for 2016, providers are encouraged to now submit data changes to Medica as they occur throughout the year — as soon as they know of a change, and at least on a monthly basis (see next article). As a result of this change, Medica will no longer request an annual data validation from providers after this year.
Reminder:
Providers need to regularly update demographic data, per CMS
As previously published, Centers for Medicare and Medicaid Services (CMS) rules require additional information for Medica’s provider directories as well as regular updates to them, beginning in 2016. The new rules state, among other things, that provider directories be accurate and updated regularly, in compliance with CMS guidance. As a result, providers need to update their practitioner and site-level demographic data in Medica’s directories as soon as they know of a change to that data, and to regularly review their demographic information for accuracy. See more details.
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Clinical News
The value of screening for pain in older adults
Pain screening is often overlooked or rushed through with the older adult population. Pain screening in the older adult comes with many complexities. Three main barriers that prevent older adults from reporting pain are:
- What the older adult believes: Older adults may believe that their pain could be associated with a terminal disease. This in turn leads to fear. Fear the disease would lead to diagnostic tests, loss of autonomy, new medications along with new side effects from the new medications and the expense that comes with a new disease. Being diagnosed with a new disease can be overwhelming and something the older adult simply does not want to deal with. Therefore their pain goes untreated.
- Lack of communication: Older adults living in a long-term-care facility fail to have their pain adequately addressed as they may feel they are a burden to the staff having to continually ask for their pain medications. They also may believe pain is a normal part of aging. Also, some older adults suffer from sensory and motor abilities that interfere with their ability to communicate their pain.
- Cognition: Older adults with a diagnosis of dementia pose a serious barrier to performing an accurate pain assessment. Clinical staff often minimizes a complaint of pain from the older adult with dementia related to inconsistent pain reports.
Patients will also deny pain but may say, “I ache,” “I hurt” or “Something doesn’t feel right.” Providers need to cue in on these remarks and investigate further. It’s important to take into account all barriers when conducting a pain assessment.
Clinical assessment
An accurate pain assessment is a must. The pain assessment ensures that the appropriate interventions are put into place. More importantly is the follow-up to the interventions. The pain assessment should include both a unidimensional measurement of pain intensity and a multidimensional, comprehensive evaluation of their pain experience. There are several types of unidimensional pain assessment tools that providers can use depending on a patient’s communication skills and cognitive ability, such as:
- Numeric rating scales (verbal or written)
- Face, legs, activity, cry, consolability (FLACC) scale
- Visual analogue scale
- Pain thermometer
- Chronic pain grade
- Pain assessment in advanced dementia scale (PAINAD)
- Patient reported outcomes measurement information system (PROMIS®) pain intensity scale
- Pictorial pain scale
- Verbal descriptor scales
- Brief pain inventory
For further information, refer to a PAINAD tool or see PROMIS studies on pain interference.
Documenting the assessment
Documentation in the medical record must include evidence that a pain assessment was performed, including the date of the pain assessment along with the findings, whether the findings are positive or negative. The Healthcare Effectiveness Data and Information Set (HEDIS®) standards state the following would not meet any of the requirements for an accurate pain assessment:
- Notation of screening for chest pain alone or documentation of chest pain alone does not meet criteria
- Notation of pain management plan alone does not meet criteria
- Notation of pain treatment plan alone does not meet criteria
Due by April 15, 2016:
Quality complaint reports required by State of Minnesota
Medica requires its Minnesota-based network providers to submit first-quarter 2016 quality-of-care complaint reports to Medica by April 15, 2016.
The State of Minnesota requires that providers report quality complaints received at the clinic to the enrollee's health plan. All Minnesota-based providers should submit a quarterly report form, even if no Medica members filed quality complaints in the quarter (in which case, providers should note “No complaints in quarter” on the form).
Providers can now send reports by e-mail to [email protected]. Otherwise, reports can still be sent by fax to 952-992-3880 or by mail to:
Medica Quality Improvement
Mail Route CP405
PO Box 9310
Minneapolis, MN 55440-9310
Report forms are available by:
Note: Providers submitting a report for multiple clinics should list all the clinics included in the report. Providers who have questions about the complaint reporting process may:
Effective June 1, 2016:
Medical policies and clinical guidelines to be updated
Medica will soon update one or more utilization management (UM) policies, coverage policies, Institute for Clinical Systems Improvement (ICSI) guidelines, and Medica clinical guidelines, as indicated below. These policies will be effective June 1, 2016, unless otherwise noted.
Coverage policies — New
| Name |
| Urine Drug Testing (UDT) in the Outpatient Setting (effective 5/1/16; see details) |
Coverage policies — Revised
These versions will replace all previous versions.
| Name |
| Autologous Blood-Derived Products (Platelet-Rich Plasma, Autologous Conditioning Serum, Autologous Whole Blood) (Merging information from inactivated policy below, Autologous Blood-Derived Products for Chronic Non-Healing Wounds) |
| Automated, Non-Invasive Nerve Conduction Testing (formerly Automated, Non-Invasive Nerve Conduction Velocity (NCV)) |
| Collagen Cross-Links Tests as Markers of Bone Turnover |
| Continuous Glucose Monitoring (CGM) Systems for Managing Diabetes |
| Genetic Testing for Thyroid Cancer (effective 3/16/16; see details) |
| Intradiscal Electrothermal Therapy (IDET) |
| Palatal Implants for the Treatment of Obstructive Sleep Apnea Syndrome |
| Urine Drug Testing (UDT) for Residential Substance Abuse Treatment (administrative update only; effective 5/1/16) |
Coverage policies — Inactivated
| Name |
| Autologous Blood-Derived Products for Chronic Non-Healing Wounds (Merging information into Autologous Blood-Derived Products (Platelet-Rich Plasma, Autologous Conditioning Serum, Autologous Whole Blood)) |
ICSI guidelines — Revised
These guidelines are available here.
| Name |
| Diagnosis and Treatment of Chronic Obstructive Pulmonary Disease (COPD) (released 2/1/16) |
| Healthy Lifestyles (released 2/1/16) |
These documents will be available online or on hard copy:
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Pharmacy News
Effective June 1, 2016:
Medica to update commercial, IFB, MHCP drug lists
Medica has reviewed the following products, with their respective coverage status to be effective June 1, 2016, unless otherwise noted. As indicated in the table below, these changes will apply to the Medica Commercial Preferred Drug List; the Preferred Drug List for individual and family business (IFB) members and small group plan members; and the Medica List of Preferred Drugs for Minnesota Health Care Programs (MHCP). The Medica MHCP formulary applies to the following products: Medica Choice CareSM (including Minnesota Senior Care Plus program, or MSC+), Medica MinnesotaCare, Medica AccessAbility Solution® (Special Needs Basic Care program, or SNBC), and Medica DUAL Solution® (Minnesota Senior Health Options program, or MSHO), for non-Part D drugs. These changes will not apply to the Medica Medicare Part D formulary.
See the full list of changes.
Medica drug formularies are available online or on paper:
Medication request forms
A uniform formulary exception request form should be used when requesting a formulary exception. It is important to fill out the form as completely as possible and to cite which medications have been tried and failed. This includes the dosages used and the identified reason for failure (e.g., side effects or lack of efficacy). The more complete the information provided, the quicker the review, with less likelihood of Medica needing to request more information. To request formulary exceptions, providers can:
Effective June 1, 2016:
Medica to update pharmacy benefit drug UM policies
Medica will soon update the following utilization management (UM) policies for pharmacy benefit drugs, effective with June 1, 2016, dates of service.
Pharmacy benefit drug UM (prior authorization) policies — Revised
Prior authorization is required. These versions will replace all previous versions.
| Name |
| tocilizumab (Actemra®) |
| certolizumab (Cimzia®) |
| icatibant (Firazyr®) |
| teriparatide (Forteo®) |
| enfuvirtide (Fuzeon®) |
| afatinib (Gilotrif®) |
| corticotropin (H.P. Acthar Gel®) |
| sofosbuvir/ledipasvir (Harvoni®) |
| mifepristone (Korlym®) |
| dronabinol (Marinol®) |
| metreleptin (Myalept®) |
| simeprevir (Olysio®) |
| abatacept (Orencia®) |
| apremilast (Otezla®) |
| peginterferon alfa (Pegasys®, PegIntron®) |
| eltrombopag (Promacta®) |
| sildenafil and tadalafil (Revatio® and Adcirca®) |
| vigabatrin (Sabril®) |
| golimumab (Simponi®) |
| bedaquiline (Sirturo®) |
| growth hormone (Norditropin® and Omnitrope®) |
| sofosbuvir (Sovaldi®) |
| ustekinumab (Stelara®) |
| paritaprevir/ritonavir/omitasvir/dasabuvir (Viekira Pak®) |
| rifamaxin 550 mg (Xifaxan®) |
These updated pharmacy benefit drug UM policies will be available online or on hard copy:
Reminder:
Drugs not FDA-approved are not covered, per member benefits
There are prescription or over-the-counter (OTC) products and kits that are currently available that haven’t been approved by the U.S. Food and Drug Administration (FDA). The FDA is working to take action against these products, but it’s a slow process. As a reminder, Medica’s plans exclude non-FDA-approved prescription products from coverage under the member’s pharmacy benefit. In the case of kits that contain an approved product, if the kit as a whole has not been approved, then the kit is not covered.
These are some products that are marketed but not FDA-approved:
- Aflexeryl-LC
- Dermacinrx Purefolix
- Dermacinrx Silapak
- Dermacinrx Surgical Pharmapak
- Dermasilkrx Diclopak
- Dermasilkrx SDS
- DS Prep Pak
- Flexepax
- Inflammacin
- Lidopatch
- Medrox
- Methaver
- Napropak Cool
- Napropax
- Nyata
- Pain Relief
- Pediapalm
- Pedipak
- Reciphexamine
- Relyyks
- Relyyt
- Renovo
- Scar
- Silazone-II
- Silvera
- Sinelee
- Synvexia
- Ticanase
- Velma
- Vexa
- Whytederm Surgipak
- Whytederm TDpak
Prescription and select OTC products that are covered are included on preferred drug lists (formularies). Providers should refer to formularies online for covered alternatives to these non-FDA-approved products. View Medica formularies.
Effective June 1, 2016:
Upcoming changes to Medica Part D drug formularies
Medica posts changes to its Part D drug formularies on medica.com 60 days prior to the effective date of change. The latest lists will notify Medicare enrollees of drugs that will either be removed from the Medica Part D formulary or be subject to a change in preferred or tiered cost-sharing status effective June 1, 2016. Medica also notifies affected Medica members in their Medicare Part D Explanation of Benefits (EOB) statements mailed out monthly. As of April 1, 2016, view the latest Medicare Part D drug formulary changes.
Medica periodically makes changes to its Medicare Part D formularies: the Medica Prime Solution® Part D closed formulary (4-tier + specialty tier) and the Medica DUAL Solution® Part D closed formulary. The Medica Medicare Part D drug formularies are available online or on paper:
Medication request forms
A medication request form should be used when requesting a formulary exception. It is important to fill out the form as completely as possible and to cite which medications have been tried and failed. This includes the dosages used and the identified reason for failure (e.g., side effects or lack of efficacy). The more complete the information provided, the quicker the review, with less likelihood of Medica needing to request more information. To request formulary exceptions, providers can:
- Download a Medica coverage determination form.
- Call MedImpact at 1-800-788-2949.
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Administrative News
Effective April 1, 2016:
Provider contracts to include a simpler, faster signing step
Agreements will use an E-signature
Medica will soon transition to electronic signatures that will be needed from network providers for certain participation agreements requiring a signature. As of April 1, 2016, Medica is making this change to enhance and expedite the contract signature process. While no action is needed at this time, once a participation agreement requires a signature, Medica will send an e-mail containing instructions on how providers can electronically sign the documents. This process improvement should improve the speed and efficiency of contracting with Medica.
Effective January 1, 2016:
Medica revises reimbursement policy
Medica has recently updated the reimbursement policy indicated below, effective with January 1, 2016, dates of service. Such policies define when specific services are reimbursable based on the reported codes.
Telehealth
The Telehealth policy has been split into two separate policies: Telemedicine and Telephone Services.
The Telemedicine policy addresses payment for the delivery of health care services or consultations while a patient is at an originating site and the licensed health care provider is at a distant site. These medical services do not involve direct, in-person contact. Included in this policy are provider assurance requirements for telemedicine specific to Minnesota Health Care Programs (MHCP) members, which were effective as of January 1, 2016.
The Telephone Services policy addresses telephone services when used to report a non-face-to-face evaluation and management (E/M) service that is initiated by an established patient, or guardian of an established patient, via the telephone. Such services are billed using Current Procedural Terminology (CPT®) codes 99441-99443 and 98966-98968.
These policies are available online or on hard copy:
Note: In addition to this reimbursement policy change, Medica has incorporated Minnesota Department of Human Services (DHS) provider assurance requirements into the Medica Provider Administrative Manual. This includes DHS provider requirements around the use of telemedicine for MCHP members. It is also an attestation by providers that they are in compliance with these requirements. Since the DHS language is incorporated into the manual, providers will not need to complete a DHS attestation form and mail it to Medica. See more about this update below.
Effective February 14, 2016:
Medica revises reimbursement policies
Medica has updated the reimbursement policies indicated below, effective with February 14, 2016, dates of service. Such policies define when specific services are reimbursable based on the reported codes.
Reimbursement policies — Revised
These versions replace all previous versions.
| Name |
| Bilateral Procedures (updated code list) |
| Global Days (updated code list) |
| Services and Modifiers Not Reimbursable to Health Care Professionals (updated code list) |
These revised policies are available online or on hard copy:
Effective February 21, 2016:
Medica revises reimbursement policy
Medica has updated the reimbursement policy indicated below, effective with February 21, 2016, dates of service. Such policies define when specific services are reimbursable based on the reported codes.
Reimbursement policies — Revised
These versions replace all previous versions.
| Name |
| Add-On Code (updated code list) |
This revised policy is available online or on hard copy:
Updates to Medica Provider Administrative Manual
To ensure that providers receive information in a timely manner, changes are often announced in Medica Connections that are not yet reflected in the Medica Provider Administrative Manual. Every effort is made to keep the manual as current as possible. The table below highlights updated information and when the updates were (or will be) posted online in the Medica Provider Administrative Manual.
| Information updated |
Location in manual |
When posted online in manual |
| Added Minnesota Health Care Programs (MHCP) provider assurance requirements for telemedicine |
“Special Contracting Requirements" section, in new "Telemedicine” subsection |
March 2016 (effective 1/1/16) |
For the current version, providers may view the Medica Provider Administrative Manual online.
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PPO News
Latest Aetna provider bulletin available online
Aetna has published its latest edition of Aetna OfficeLink UpdatesTM (March 2016). Highlights that may be of interest for Medica SelectCareSM network providers include:
- Multiple drugs added to Aetna’s National Precertification List — now effective
- Precertification required for inpatient and outpatient procedures — now effective
- Member ID cards presented on a smartphone are valid proof of coverage
- Payment change for professional services in a hospital — scheduled for August 2016
View the March 2016 Aetna provider bulletin.
Latest UHC provider bulletin available online
UnitedHealthcare (UHC) has published the latest edition of its Network Bulletin (March 2016). Highlights that may be of interest to LaborCare® network providers include:
- Changes to Provider Remittance Advice (PRA) — now effective
- Prior authorization to be required for select musculoskeletal and pain management procedures — scheduled for April 2016
- New Intensity-Modulated Radiation Therapy Policy — scheduled for June 2016
- Prior authorization to be required for genetic testing — scheduled for third quarter 2016
View the March 2016 UHC provider bulletin.
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