11/5/2018

1

Priority Health and MiMGMA

November 2018

Agenda UM re-engineering and local rules eviCore Relaunch Authorizations process New products General news and reminders

UM Re-Engineering

Karen MeyersonDirector, Care Management

Process Improvement

11/5/2018

2

UM re-engineering Goal of the presentation today:

Upcoming goals for utilization management Local rules Overview of communication and training plan

Whats needed from provider network: How can we better streamline communication and training? Engage your facilities and teams to communicate the upcoming

changes

4

Our vision CHANGE, the way care is

delivered and reimbursed to reduce the cost of care

ENGAGE, members in their health and with us to lower the total cost of care

INNOVATE, to touch more lives and improve the financial performance of our products and services.

Proactive interventionsMember engagement Platform and Process

Re-engineering

Priority Advantage Shared Service

Multi Channel Interface with Members

Performance mgt. & guidance

True Personalization

UM re-engineering

6

Right care

Right time

Right place

Right price

11/5/2018

3

UM re-engineering Utilization management

Two pronged Process go-live 12/1/18 Platform estimated 2020

7

Local Rules Data driven

Review of claims data submitted from our providers over time

Reviewed diagnoses and length of stay Determined that members with these diagnosis

tend to be admitted, treated with good response and discharged within 24 - 48 hours

8

Benefits to facilities Observation stays do not require prior

authorization Fewer appeals More rapid response for true inpatient

authorization requests

9

11/5/2018

4

Local Rules

10

Priority Health local rules list Other plans in the State of MI

Cardiac - CHEST PAIN OTHER THAN ACUTE MI, AFIB, SYNCOPE AND HTN URGENCYATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITH UNSTABLE ANGINA PECTORIS, HYPERTENSIVE HEART DISEASE WITH FAILURE

Pulmonary - PNEUMONIA, COPD, ASTHMA

Endocrine - DM

Gastrointestinal (GI) - ABD PAIN, CHOLEYCYSTITIS, GI BLEED, APPY, DEHYDRATION, ILEUS, GASTROENTERITIS, ANEMIA

ID - CELLULITIS, UTI, POST OP INFECTION

Genitourinary (GU) - AKI, STONE

11/5/2018

5

Local RulesGastrointestinal (GI)

13

ICD10 Diagnosis Description

K80.00 CALCULUS OF GALLBLADDER WITH ACUTE CHOLECYSTITIS WITHOUT OBSTRUCTION

K56.60 UNSPECIFIED INTESTINAL OBSTRUCTION

K92.2 GASTROINTESTINAL HEMORRHAGE, UNSPECIFIED

K52.9 NONINFECTIVE GASTROENTERITIS AND COLITIS, UNSPECIFIED

K92.1 MELENA

K35.3 ACUTE APPENDICITIS WITH LOCALIZED PERITONITIS

E86.0 DEHYDRATION

K56.69 OTHER INTESTINAL OBSTRUCTION

K81.0 ACUTE CHOLECYSTITIS

A09 INFECTIOUS GASTROENTERITIS AND COLITIS, UNSPECIFIED

D64.9 ANEMIA, UNSPECIFIED

Local RulesInfectious Disease (ID)

14

ICD10 Diagnosis Description

T81.4XXA INFECTION FOLLOWING A PROCEDURE, INITIAL ENCOUNTER

N39.0 URINARY TRACT INFECTION, SITE NOT SPECIFIED

L03.115 CELLULITIS OF RIGHT LOWER LIMB

L03.116 CELLULITIS OF LEFT LOWER LIMB

L03.114 CELLULITIS OF LEFT UPPER LIMB

L03.113 CELLULITIS OF RIGHT UPPER LIMB

Local RulesGenitourinary (GU)

15

ICD10 Diagnosis Description

N17.9 ACUTE KIDNEY FAILURE, UNSPECIFIED

N13.2 HYDRONEPHROSIS WITH RENAL AND URETERAL CALCULOUS OBSTRUCTION

E87.1 HYPO-OSMOLALITY AND HYPONATREMIA

11/5/2018

6

Local Rules

16

NeuroICD10 Diagnosis Description

I63.9 CEREBRAL INFARCTION, UNSPECIFIED

I63.8 OTHER CEREBRAL INFARCTION

G45.9 TRANSIENT CEREBRAL ISCHEMIC ATTACK, UNSPECIFIED

R53.1 WEAKNESS

G40.909 EPILEPSY, UNSPECIFIED, NOT INTRACTABLE, WITHOUT STATUS EPILEPTICUS

G40.409 OTHER GENERALIZED EPILEPSY AND EPILEPTIC SYNDROMES, NOT INTRACTABLE, WITHOUT STATUS EPILEPTICUS

Local RulesMiscellaneous

17

ICD10 Diagnosis Description

Z51.89 ENCOUNTER FOR OTHER SPECIFIED AFTERCARE

Z47.1 AFTERCARE FOLLOWING JOINT REPLACEMENT SURGERY

Z47.89 ENCOUNTER FOR OTHER ORTHOPEDIC AFTERCARE

Z48.89 ENCOUNTER FOR OTHER SPECIFIED SURGICAL AFTERCARE

I82.402 ACUTE EMBOLISM AND THROMBOSIS OF UNSPECIFIED DEEP VEINS OF LEFT LOWER EXTREMITY

I82.621 ACUTE EMBOLISM AND THROMBOSIS OF DEEP VEINS OF RIGHT UPPER EXTREMITY

UM re-engineering Increased focus on reviewing for InterQual

criteria Making sure patient meets criteria

Most appropriate level of care

18

11/5/2018

7

How are we sharing this new process? Communication

Conversations with facilities prior to 10/1 Initial notification went out 10/1 to ACNs Joint Operating Committees (JOCs), Virtual Office Advisory(VOAs)

Training Webinars and in-person training began mid-October

Post Go-Live Support Follow-up trainings Single point of contact

19

Platform 2020

Search for a new platform for 2020 Clear Coverage support ends 1/2020 Researching platforms

Demonstrations occurring 10/3-10/5 Finalize contract 12/7

End-user friendly Priority Health has an opportunity to select a technology platform

that will better align medical management programs: care management, utilization management as well health coaching and wellness initiatives around a collaborative, holistic view of each member.

21

11/5/2018

8

eviCore Relaunch

eviCore Relaunch UpdateWhat has changed A subset of the high-tech radiology CPT codes requires medical

necessity review; other codes remain on prior notification/auto-approval. Decision is made within two (2) business days of receipt of all clinical information.

Whats not changing Musculoskeletal procedures remain on prior notification/auto-

approval until weve finalized an improved process. Genetic testing remains on prior authorization.

eviCore Relaunch UpdateProgram enhancements To address the concerns that too many cases went into pend status

without the ability to enter in all relevant data, we have changed the process flow to allow for more real time throughput on the web.

Features have been added to allow the data entry process to be more efficient. These functionalities include back button, duplicate, and save/finish later.

Adjustments were made to the data exchange process from Priority Health to eviCore to ensure member or provider not found messages are reduced.

11/5/2018

9

eviCore Relaunch UpdateProcess and resource enhancements Enhanced peer-to-peer scheduling process to reduce wait times,

provide more reliable access to eviCore clinicians, and allow for better specialty matching.

Increased Customer Service and RN resources at eviCore to minimize hold times when calling for general questions or case determinations.

Clinical enhancement Requests are not delayed or denied based on contrast rules.

eviCore Relaunch UpdateEnhanced Clinical Pathways Opportunity for real-time authorization for:

o CTs and MRIs of the pelvis for the initial staging of Prostate Cancero CT chest, abdomen and pelvis for initial staging and restaging of Kidney Cancero CT chest for Lung Cancer diagnosis/stagingo MRI Brain

eviCore Relaunch UpdateEnhanced Clinical Pathways Other oncology conditions have been added:

o Anal and Vaginal Cancero Esophageal Cancero Gastric Cancero Gastrointestinal Stromal Tumor (GIST)o Merkel Cell Carcinomao Ovarian Cancero Pancreatic Cancero Renal Cell Cancero Transitional Cell Cancero Primary Central Nervous System Tumor

11/5/2018

10

Authorizations

Provider center

Request an authorization

11/5/2018

11

Authorizations You can access online PA tools through our

single sign on tool Enter the place of service and procedure

code, and youll be automatically directed to the proper PA tool

https://www.priorityhealth.com/app/ProviderClearCoverageSsoUi/

31

Authorizations For services that require an authorization, for

in-network providers, use the Clear Coverage PA online tool

The eviCore PA tool is used for high-tech imaging, labs or genetic tests

32

Requesting a prior authorization

ABC 123 ORTHOPEDIC

11/5/2018

12

Auth reference list link

Auth reference list link

Drug authorization request

11/5/2018

13

Authorizations Authorization requirements are implemented on

a quarterly basis All authorization and medical policy changes are

reviewed by an inter-disciplinary team of both Priority Health and external participants

https://www.priorityhealth.com/provider/center/auths

37

Authorizations Once an authorization has been submitted, you

can check the status through the requesting tool (Clear Coverage or eviCore) or via Auth Inquiry Auth inquiry only will populate information that your

office originally requested Cannot see other facility auths for your patient

https://www.priorityhealth.com/app/AuthInquiry/Account/Index

38

Provider center

11/5/2018

14

Authorizations If you need a tutorial or guide on how to use any of our

online PA tools, you can find pre-recorded webinars for both online:

https://www.priorityhealth.com/provider/center/auths/auth-request-help

Drug authorizations, behavioral health, skilled nursing, long-term acute care and hospice are not available to be requested online, and a paper authorization request is needed

40

Authorization tool help

41

Authorization tool help

42

11/5/2018

15

New products coming in 2019

Chelsea SelbigProvider Communications

Beaumont narrow network Beaumont narrow network expansion effective Oct. 1 Expanded to include community-based physicians

participating in the United Physicians (UP) Provider Organization who have privileges at Beaumont Health hospital facilities

Find-A-Doctor tool is currently updated to include these providers in the Beaumont narrow network

44

Spectrum Health employer group tiered network

Spectrum Health employer group tiered network is a new plan effective Jan. 1

All offered plans for 2019 will be within a tiered network, meaning members will pay different costs depending on the providers and facilities they use

45

11/5/2018

16

Spectrum Health employer group tiered network

Members who live in the following counties will have to choose a tiered network plan: Allegan, Barry, Ionia, Kent, Montcalm, Muskegon and Ottawa

Providers in tier 1: Spectrum Health physicians Holland PHO Answer Health shareholders and affiliates We Are For Children Health Pointe Neonatal Associates Pediatric Surgeons of West Michigan Pathology, anesthesiology, radiology and emergency room physicians serving a Spectrum

Health or Holland hospital

46

Southeast Michigan Partners tiered network

Southeast Michigan Partners tiered network is a new plan effective Jan. 1

Employers in Oakland, Macomb, Wayne, Washtenaw, St. Clair, and Livingston counties have a tiered network option

Together Health Network will be Priority Healths provider partner for participation in the network for tier 1 benefits

47

Southeast Michigan Partners tiered network

Providers in tier 1 include: St. John, Providence Park, and

Ascension Crittenton hospitals and select affiliated physicians

St. Joseph and St. Mary Mercy Livonia hospitals and select affiliated physicians

Lake Huron Medical Center and all affiliated physicians

Michigan Medicine (University of Michigan and health centers) for non-primary care with referral only

48

11/5/2018

17

Partnership with Cigna Weve entered into an agreement with Cigna Payer Solutions which

provides two significant opportunities: Provide access for our members of commercial employer groups and

individual plans with an extensive travel network outside of Michigan also known as: travel network with Priority Health as primary network

For Michigan employer groups that have employees residing outside of Michigan, Cigna is now another option for out-of-state primary network with ability to access Cignas almost 1 million national providers and their robust discounts also known as: Cigna as primary network

49

Partnership with Cigna Cigna access is effective starting Oct. 1 for some plans

and Jan. 1 for all others Only for commercial plans

50

How to bill Cigna For Providers in Michigan:

You must submit claims directly to Priority Health For Providers outside of Michigan participating with Priority Health:

Your existing contract will be utilized and you must continue to submit claims directly to Priority Health

For Providers outside of Michigan that do not participate with Priority Health: The Cigna PPO Network is our preferred network for out-of-state

coverage. Please refer to the members ID card for billing instructions

51

11/5/2018

18

Our website can assist you

Web resources Online news and education

We regularly post articles to the news and education page on topics from general clinical reminders to major program changes

This is our main method of communication with the provider network

https://www.priorityhealth.com/provider/center/news

53

Web resources

54

Find the latest provider news

See all news by selecting a category

11/5/2018

19

Web resources Video library

Demo videos of our online tools, such as member inquiry, Clear Coverage prior auth, and edit checker are available on-demand

https://www.priorityhealth.com/provider/center/news/video-library

55

Web resources

56

Web resources Virtual office advisory webinars

Hosted bi-monthly and cover a variety of topics

Webinars are recorded and posted to the video library

https://www.priorityhealth.com/provider/center/news/voa

57

11/5/2018

20

Web resources

58

Register for 2019 VOAs The VOAs for 2019 have been pre-scheduled

and are available for registration on the VOA webpage

https://www.priorityhealth.com/provider/center/news/voa

What do you want to hear about? Please provide your suggestions to the Q&A box

59

General reminder

11/5/2018

21

Influenza billing Priority Health has observed an increase in Medicare influenza and pneumonia vaccine claims being billed with commercial, noncovered codes This causes the patient to pay out of pocket for the administration of that vaccine Please review our Covered Part B vaccine administration codes on the Immunizations under Medicare Parts B & D webpage for covered codes

61

Influenza billing

62

https://www.priorityhealth.com/provider/center/services/preventivecare/medicare/medicarevaccines

Questions

11/5/2018

22