Providers - What's New for Providers

What's New for Providers

Care Support and System Innovation (CSSI) Program

The CSSI Program seeks to support provider organizations that identify and support teams to lead projects and initiatives that improve health care delivery and outcomes. These teams will use the Model for Improvement to create change in their organizations. Each project demonstrates improved design, outcomes reporting, institutional commitment and capability. Read more…

OHP Plus dental and vision service changes in 2010

Effective Jan. 1, 2010, certain dental and vision benefits will no longer be available to OHP Plus clients who are 21 years or older and not pregnant. This page provides resources to prepare clients, providers and managed care plans for this change.

Influenza A (novel H1N1) virus: Continue vaccinating

As of early February 2010, flu activity is relatively low. Most flu cases are caused by 2009 H1N1 viruses, with very little seasonal flu. Flu activity, caused by either 2009 H1N1 or seasonal flu viruses, varies, but it is expected to continue for several more months.

CDC recommends influenza vaccination as the most important step in flu prevention. CDC encourages that everyone be vaccinated against 2009 H1N1, including people 65 years and older. While less common than with seasonal flu, severe illnesses and deaths from 2009 H1N1 have occurred in every age group, including people 65 and older.

Vaccination of people with certain health conditions is especially important because they are more likely to get serious flu-related complications. Health conditions that increase the risk of being hospitalized from 2009 H1N1 include lung disease like asthma or chronic obstructive pulmonary disease (COPD), diabetes, heart, neurologic disease and pregnancy.

CareOregon appreciates your help in fully immunizing our members. Please call Joyce Caramella at 503.416.8026 or toll-free 1.800.224.4840 if you have questions or want member and provider educational materials.

Content source: 2009 H1N1 Flu, Centers for Disease Control and Prevention

Resources:

Consultation codes no longer accepted for billing

Effective immediately CareOregon follows CMS guidelines and no longer accepts consultation codes (99241-99245 and 99251-99255) for all lines of business. Providers should code a patient evaluation and management visit with E/M codes that represent where the visit occurs and the complexity of the service performed.

This policy applies to services provided on and after January 1, 2010. CareOregon still covers consultation office visits for our members when medically appropriate. Remember to code the visit correctly with E/M codes.

For more information on our prior authorization guidelines, refer to the “Medical Management Policies and Forms” section on our website, www.careoregon.org/provider/policies.html.

The following URL is an article from CMS about this change: www.cms.hhs.gov/MLNMattersArticles/downloads/MM6740.pdf.

The official instruction, CR6740, issued to Medicare MACs and carriers about this change is at www.cms.hhs.gov/transmittals/downloads/R1875CP.pdf.
Documentation guidelines for Evaluation and Management Services are at www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asp.

If you have questions or need help, please call CareOregon Customer Service at 1-503-416-4100 or toll-free at 1-800-735-2900.

Primary Care Quality Measurement Reports Going Public

In late February 2010, the Partner for Quality Care initiative will publicly report performance scores for clinics and medical groups with four or more adult primary care physicians on nine quality measures. Information about individual physicians will not be included. Physicians may see more detailed reports, including patient-level data and how scores were determined, on a secure web site. To access the secure web site, medical groups must have a signed Business Associate Agreement on file with the Partner for Quality Care initiative, which can be found at: PartnerForQualityCareForPractitioners.org.

Key Dates

February 5, 2010 – Physician review and comment period ends.
February 2010 – Public reporting of performance scores for clinics and medical groups with four or more adult primary care physicians will be posted in late February on the public web site: PartnerForQualityCare.org.

Contact the Partner for Quality Care initiative for more information:
Email: info@PartnerforQualityCareforPractitioners.org
Phone: 503-241-3571

Nurse Flu Advice Line Closed

As the number of H1N1 cases has diminished, so has the need for the state’s Access to Care Flu Nurse Call Center, operated by CareOregon. The advice line will no longer be active as of January 27. It may be reactivated should the need arise.

Health Care Improvement Initiative Underway in Oregon

As health care reform undergoes the twists and turns of the legislative process, an initiative aimed at measuring and improving health care in Oregon is already underway. Through the collaboration of health plans, physicians and patients, the Partner for Quality Care: Information for a Healthy Oregon initiative provides information to primary care practitioners and to patients to assist in achieving high quality health care.

Primary care practitioners will receive paper-based reports (via their medical group administrator) in early January. These reports assess the care given to patients on a few measures of primary care and are aggregated from claims data from eight of Oregon’s largest health plans. A unique aspect of the initiative is that practitioners can also access more detailed reports, including patient-level information, on a secure website: PartnerForQualityCareForPractitioners.org.

In mid-February all Oregonians will be able to see how primary care clinics compare on a public website: PartnerForQualityCare.org. The website also provides comparisons of hospitals and offers tips for patients on how to become more involved in their health care.

Two RNs are available to review reports with clinic administrators and develop quality improvement activities in clinics. For more information, email: info@PartnerForQualityCareForPractitioners.org or call: 503-241-3571. You can also download the Partner for Quality Care overview or a selection of Frequently Asked Questions.

Express Scripts to be Pharmacy Benefit Manager!

Effective January 1, 2010, Express Scripts, Inc., will be our Pharmacy Benefit Manager. Click here to review details of this change.

Please notify your staff of these upcoming changes:

Phone number for after-hours pharmacy benefit assistance will be 1-877-526-2313.

Note: For help Monday-Friday 8 a.m. to 5 p.m. and to request an appeal or reconsideration for a denial, please continue to call CareOregon at 503-416-4100 or 800-416-4240.
We’ll tell you the new fax number for Rx prior authorizations and formulary exceptions as soon as possible. We’ll alert you when revised prior authorization forms are posted on our web site.

If you have questions, please call CareOregon Customer Service at 1-503-416-4100 or toll-free 1-800-224-4840.

Prior Authorizations for Medical services alert!

CareOregon is implementing a new document management system for medical prior authorizations. This system will allow incoming faxes to be immediately seen in a paperless system.

The new system will benefit our providers because all documents will be searchable. The ramp-up period may add processing time to service requests. Our average turnaround is three days. Authorizations that require more information or medical-director review may take longer. We anticipate an increase to seven days during implementation. Please consider this when requesting a service – the longer the lead time you can give us, the better.

Also, if a service is scheduled, please include the date on your request. We anticipate that this impact may last 4 to 6 weeks. Thank you for your patience during implementation.

Provider Services forms teams to serve you

To increase collaboration and better support our clinicians, we have created three teams within the Provider Services Department. Effective Monday, October 5, Network Relations Associates are assigned to par and non-par providers based on teams (PCP, specialty and hospital) instead of territories.

Download the updated Team Assignment List or access it on the Resource List page of this web site.

This team approach is tailored to meet the specific needs of your office or facility. An NRA will contact each provider or clinic to set up a time to meet with you at your convenience. If you have concerns, please call Karry Donnelly, Network Relations Supervisor, at
503-416-1483.

Hiding Won’t Work… ICD-10 is coming!

CareOregon is actively preparing for the change to ICD-10. We are committed to helping our partners in healthcare prepare, too. Keep an eye out for more information as we get closer to key dates.

CMS has mandated that the 30-year-old ICD-9 diagnostic coding system be replaced by the more flexible ICD-10 CM and PCS system. The advantages of this change include greater clinical detail and updated medical terminology. For example: ICD-9 has a single code for an injury of a lower limb nerve. ICD-10 CM has more that 40 choices depending on criteria such as which nerve, which side and where the patient is in the treatment timeline, from the initial visit through any late effects of the injury.

The deadline for nationwide conversion is October 2013. Part of the preparation for this change includes updating from the HIPAA 4010 transaction record to the 5010 version to accommodate the new seven digit diagnosis and procedure codes. The deadline for full implementation of the 5010 is January 2012.

We are on track to begin external testing of the 5010 by the required January 2011 date.

For more ICD-10 and 5010 information including key dates, please visit http://www.cms.hhs.gov/ICD10/01_Overview.asp#TopOfPage

For questions specific to CareOregon’s preparations, please contact your Network Relations Associate.

Legacy Bone Clinic has moved!

In 2004 CareOregon and Legacy Health System began collaborating to address orthopedic care needs. They formed the Legacy Bone Clinic for CareOregon/OHP and CareOregon Advantage/Medicare patients. The Bone Clinic recently moved to the Legacy Emanuel Hospital campus, 3001 N. Gantenbein Avenue, in north Portland. The clinic is staffed by Robert Earl, PA.

The Bone Clinic welcomes referrals for the following services:

Ongoing orthopedic care from the first emergency department visit through completion of care
Orthopedic evaluation and treatment by a physician’s assistant, including splints, bracing, taping and casting
Fractures not requiring surgery
Evaluation of orthopedic bony complaints
Joint injections
Easy access to orthopedic services, diagnosis and referrals to a surgeon, as needed

Prior authorizations are not required to refer members to the Bone Clinic.

Please click for additional clinic details. Complete the referral form and follow instructions.

If you have questions about the Bone Clinic, contact your CareOregon Network Relations Associate.

The CareSupport Program

The CareSupport Program provides multidisciplinary, person-centered case management services to CareOregon members who: (1) are at risk for or experiencing a functional health decline because of lack of appropriate supports or self management, (2) are using the health care system ineffectively or inappropriately, or (3) are experiencing a significant health-related transition in their life, such as hospital discharge to home with advanced disease. CareSupport staff work to optimize the productive interaction between the patient and provider, working closely with both the patient in becoming informed and activated and the medical team in being prepared and proactive in the medical home.

Please review additional information about the CareSupport Program and how we can work with you to improve the health of your patients.

CareNews

CareNews delivers relevant, thought-provoking, engaging and entertaining information about new provider programs and initiatives. Celebrate the accomplishments of health professionals who are making a difference, every single day. Learn about how clinic and hospital staff are implementing innovative ways of delivering care. View the latest edition of CareNews.

Medicare Advantage

CareOregon Advantage provides Medicare and Part D prescription drug benefits to qualified members. You can enroll in CareOregon Advantage if you are eligible for both Medicare and Medicaid coverage and live within a nine-county service area: Clackamas, Clatsop, Columbia, Jackson, Josephine, Marion, Multnomah, Polk and Washington.

Completed surveys from recently enrolled CareOregon Advantage Members were recently mailed to Providers. Based on these surveys, if you wish to refer a CareOregon member to the CareSupport Team assigned to your practice, please complete this referral form and fax it back to us at the number indicated on the bottom of the form. It is extremely helpful if you indicate the type of support that you feel would most benefit your patient as indicated on the referral form.
Primary care providers who participate in our Medicare Advantage plan are responsible for obtaining a signed advance directive from each Medicare member and placing it in the member's chart, or have documentation showing that the member refused to sign an advance directive. Click here to view and print a copy of the advance directive form. To learn more about advance directives, click here.

Visit our Medicare web site: www.careoregonadvantage.org for more information about this plan.

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