Updates from Network Relations |
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Provider Relations is now Network Relations  You’ve known us as Provider Relations Associates. We’ve been pondering a name change that would encompass all the groups we work with—hospitals, vendors, physicians, nurse practitioners, office staff and more. The “relations” piece is the core of our work, so that stays. All of us are partners working on common goals, so “associates” came to mind as an appropriate label. Voila! Our new job title: “Network Relations Associates.” We have also made some adjustments to the areas we cover, and have added a new associate, Monica Jackson. We’ve made no changes in how you reach us. Just check our web site for a list of territories, phone numbers and e-mail addresses. Jackson County transitions to managed careBy Peter McGarry  In Jackson County, some 10,000 Oregon Health Plan members are transitioning from fee-for-service “open card” status to managed care. By the end of July, 6,000 of these OHP members are projected to be assigned to CareOregon. Most managed care plans stopped providing care for Jackson County Medicaid members in 1999, citing financial losses. The Department of Human Services’ Division of Medical Assistance Programs (DMAP) has determined that enough managed care organizations are now providing care to Medicaid patients. Consequently, DMAP is requiring the change to managed care. DMAP is making assignments to the different plans, but we want members to know that they can change plans if they need to. CareOregon has been the sole health plan with significant Medicaid membership in Jackson County over the past 10 years. CareOregon has expanded our network of providers so that we can provide services to new Medicaid members transitioning to managed care. For Oregon Health Plan members, CareOregon membership means access to the services of CareOregon’s CareSupport Program for people who need extra help for their health.. CareSupport teams, including nurses, behavioral health specialists, pharmacists and Health Care Guides, provide the expanded services that help people who have multiple conditions or chronic conditions, or who have issues of poverty. There is considerable research to show that this extra help can help patients be more successful with treatment plans developed by their providers. (See related story.) Upon enrollment with CareOregon, members will receive an insurance card and welcome packet that explains how to get access to care through CareOregon’s network of providers. It will also explain CareOregon’s coverage of medications. The doctors and pharmacists on CareOregon’s Pharmacy and Therapeutics Committee ensure that our members have access to a high quality pharmacy benefit based on the Prioritized List of Health Services, efficacy, safety and value. The welcome packet introduces our members to the CareOregon formulary and the formulary exception process. (See related story.)
 In this issue...Did you know? Providers are submitting more electronic claims to CareOregon than ever before. If you’d like to join the providers whose claims get paid in as quickly as 10 days, call us at 1-800-224-4840. In this issue of CareOregon…In Your Corner, we share information about CareOregon’s recent operational performance and some interesting facts about our membership. In Your Corner is one way we’re keeping in touch with you. Your office should have received a copy already. If not, you can download an electronic version of the most recent issue here. In CareLinkIn the spring issue of CareLink, our member newsletter, we shared these stories: being prepared for disasters, the importance of pertussis vaccines and preventive tests for people with diabetes. Read the online version here. Coming up in the summer issue: a focus on being active in the summer time. We’ll share tips for keeping bodies and minds active during those months away from school. Read the online version here. Meet a Network Relations Associate: Sharon Madara Sharon Madara is the CareOregon Network Relations Associate with the most remote territory. Count providers in Clatsop, Columbia, Jackson, Josephine and Klamath counties among her contacts. But CareOregon’s service area outside the Portland metro area is more like home for Sharon, a graduate of Medford Senior High School. She still has family in the area, and hangs out with a group of friends who’ve stuck together since grade school. Sharon has been a Network Relations Associate for three years. Before that, she worked in various positions in health care. “I kind of backed into it,” she says. “I got my degree at the University of Oregon and moved to Portland. “I had a psychology major with a minor in counseling. That and two bucks would get you a cup of coffee.” So, in 1980, she tried medical administration instead. “It’s been fun,” she says. “I think I bring a unique perspective because I have been on the clinic side. I’ve worked in billing. I’ve worked at OHSU. I’m intimately familiar with financial issues. “I have a lot of empathy for staff. I’ve been in their shoes. I really appreciate the job that they do. I don’t see it only from the insurance side.” That empathy is what attracted Sharon to CareOregon. “Here, it’s not just dollars and cents,” Sharon says. “If there is anything I can do as a Network Relations Associate to make things less stressful, if providers know they have a person they can go to that understands, then that’s doing my job.” The most rewarding part of Sharon’s job is acting in the role of teacher, facilitating better teamwork with CareOregon and the provider: helping those new to the Oregon Health Plan understand it, and showing how to interact with CareOregon’s systems and practices. Recently Sharon had a lot of time back in her home town. “The experience in Jackson County has been taking up the majority of my time,” says Sharon, who made several presentations to new providers in Medford. “I still have my Black Tornadoes emblem, but I didn’t put it on,” she says. Welcome Monica Jackson
“We’re excited to have Monica with us,” said Karry Donnelly, Network Relations Supervisor. “She worked in the medical field prior to coming to CareOregon. That gives her an understanding of the challenges our providers face on a day-to-day basis." During her time at CareOregon, Monica also has been a Utilization Management Assistant. Both of these positions have allowed her to understand the details of prior authorizations for medical and pharmaceutical care. This knowledge will be invaluable when educating clinic staff on policies and procedures." Monica will be Network Relations Associate for Legacy Health System, Children’s Health Alliance clinics (formally Pediatric IPA), all non-system Washington county PCP and specialty clinics, and all PCPs, specialists and hospitals in Morrow, Umatilla and Walla Walla counties. A reminder about Notices of Medicare Non-CoverageCMS requires the form for SNF, HHA and CORF providers The Centers for Medicare and Medicaid Services (CMS) has asked us to remind providers of Skilled Nursing Facility (SNF), Home Health Agency (HHA) and Comprehensive Outpatient Rehabilitation Facilities (CORF) services of their need to give approved official notices to Medicare enrollees when their covered care is ending. CareOregon will provide the “Notice of Medicare Non-Coverage” form to providers at the time SNF, HHA or CORF services are authorized (see a sample of CareOregon’s NOMNC form for skilled nursing here). However, the SNF, HHA or CORF, not CareOregon, is responsible for delivering the notice to enrollees. The notice must be delivered at least two days before the proposed termination of services. The notices must be provided to Medicaid enrollees even if the enrollee agrees that services are to be terminated. The notice must be validly delivered, which means that the enrollee must be able to understand the purpose and contents of the notice and sign for receipt of it. The enrollee must be able to understand that he or she may appeal the termination decision. If the enrollee is not able to comprehend the contents of the notice, it must be delivered to and signed by a representative. The notice also includes information about the Medicare member’s appeal rights, including the name and telephone number of Acumentra, the Quality Improvement Organization that handles appeals termination of SNF, HHA and CORF services. Providers have the option of including additional information on the notice. This does not substitute for the delivery of a Detailed Explanation of Non-Coverage, which is required when a Medicare member appeals. Don’t use the NOMNC if coverage is being terminated for any of these reasons: • The Medicare benefit is exhausted. • Medicare admission is denied. • Non-Medicare covered services are denied. • Medicare services are being reduced or terminated, but the skilled Medicare stay is not ending. In these cases, CMS form 10003, “Notice of Denial of Medical Coverage (NDMC)” is used. You can find information on CMS' regulations and changes on its web site. A prescription for successRecently CareOregon asked a member focus group what we can do to help make their care experience better and be more active participants in their care. It’s important for us. We’ve seen the research showing that patients who are pleased with their care experience are more compliant with the treatment plans developed by their providers and have better outcomes. One topic raised by the group related to medications. This spring we are testing tools to make it easier for members to comply with providers’ desire for patients to bring their medications to each office visit. We’re developing these tools with help from members and providers. We also letting members know about the importance of asking questions about new prescriptions before they leave the doctor’s office:
We wanted to keep you informed about these efforts to improve the care experience for CareOregon members. We’ll keep you advised as we develop other tools as well. New bariatric surgery benefitsBy Karry Donnelly Obesity treatment is now covered for Oregon Health Plan members. The Oregon Health Services Commission authorized funding for these services effective January 1, 2008. CareOregon requires prior authorization for these services: Medical treatment
Surgical treatment
For medical treatment referrals to a licensed dietitian, please use the standard CareOregon authorization form. For referrals to a bariatric surgeon at OHSU Bariatric Center, please use the new prior authorization form. There is more information on the Division of Medical Assistance Programs (DMAP) web site. Prior authorization updateYou asked us to update our medical-related services prior authorization lists, and we’ve made those changes. Based on feedback from our network of providers and from our Prior Authorization Department team, we’ve changed the CareOregon OHP Plus and CareOregon Advantage prior authorization lists:
If you have questions, feel free to contact your Network Relations Associate. CPT®—Current Procedural Terminology—is a registered trademark of the American Medical Association. Thank you for your help We depend on your help to know how we can make CareOregon better. Thank you to the 10 clinics that returned our Provider Satisfaction Survey this year. We’ve sent each of them a $30 Visa gift card.
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Monica Jackson is our newest Network Relations Associate. She’s been with CareOregon eight years, and comes to Network Relations from the Medical Management Pharmacy Unit, where she was a pharmacy program technician.