optum care network provider binder

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© 2020 Optum, Inc. All rights reserved. Revision 062021

Optum Care Network Provider Binder

Section 1: OCN Information

Section 2: Provider Alerts

Section 3: Attestations

Section 4: Provider Manual

Section 5: Prior Authorization

Section 6: Optum Care Provider Center - Portal

Section 7: Risk Adjustment, Quality, & Patient Satisfaction

Section 8: Optum Outreach & Wraparound Services

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© 2021 Optum, Inc. All rights reserved.

Led by physicians. Powered by collaboration. Driven by better.

The Optum Care Network of Washington helps people live their best lives. To be a physician here is to practice medicine first and foremost. Our value-based model lets you focus on patient and care for your wellbeing as well as theirs.

We efficiently coordinate a state-wide ambulatory care network of employed clinicians and affiliated medical groups for multiple payers, including federal, state and commercial health plans. The benefits of physicians are significant – you get the support of a health care industry leader while you remain independent and able to make your own decisions. You also get a national team of doctors connecting your care to the latest evidence-based breakthroughs. A collaborative team always has your back so you can provide affordable, high-quality health care for Washington’s diverse populations.

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Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. © 2021 Optum, Inc. All rights reserved.

FAQ OCN, Network Partner

OCN Frequently Asked Questions What is Optum Care Network OCN? Optum Care Network (OCN) is a physician-led, patient-focused health care delivery network headquartered in King County, Washington. OCN is part of Optum, a UnitedHealth Group company. OptumCare entities, delegated by Medicare Advantage Organizations, specialize in the complete coordination of care for Medicare Advantage Enrollees. OCN will be responsible for arranging medical services, claims processing administration, and utilization management for Medicare Advantage Enrollees and other select providers of various Payors. OCN will partner with you to improve health outcomes as well as the health care experience for our Medicare Advantage enrollees.

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Is OCN a health plan? No, OCN is not a health plan. OCN is a first-tier entity of Medicare Advantage and Medicaid Managed Care organizations. OCN arranges and manages care authorizations and claims on behalf of the health plan sponsor. OCN is currently delegated for the following health plans: Humana, Premera and UHC. Is OCN a part of The Everett Clinic (TEC) and The Polyclinic (TPC)? OCN contracts with TEC and TPC in the same way they contract with other network provider groups in order to be able ensure that OCN’s delegated membership has an adequate network of providers. OCN is a separate legal entity from the care delivery organizations (CDO’s) such as TEC and TPC. What is Optum Care Provider Center (OCPC or OPC)? Optum Care Provider Center, sometimes referred to as OPC, is a provider portal accessed via OneHealthPort single sign-on. From OPC providers can view members, claim status, submit for prior-authorization, review provider resources and access PCP reporting. Attestations can be accessed and completed under the PCP Reporting tab. Patient access list based on factors such as quality care gaps, missing HCCs, etc. can also be tracked under the PCP reporting tab. What are attestations? Attestations are a communication tool between OCN and Network PCPs to assist with accurate and complete documentation and coding of chronic conditions. The accurate capture of chronic conditions allows for appropriate risk adjustment for the population that providers serve. OCN gathers data from multiple sources to present known and suspected HCC codes on the attestations. These sources include claims data as well as clinician chart review. Attestations have been a successful method to assist providers as they become more comfortable with HCC coding and understanding Risk Adjustment. OCN recognizes the additional time and effort that goes into reviewing and completing attestations; therefore, an incentive is available for each completed attestation accompanied by a supporting chart note for respective date of service (DOS).

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What is the Practice Engagement Manager (PEM) role? Each OCN provider group is assigned a Practice Engagement Manager. Your PEM, together with their Network Medical Director dyad, work to help you succeed in achieving increased quality, patient experience, more accurate documentation, care management, affordability, and growth.

Practice Engagement Manager Responsibilities • Primary Single Point of Contact with Clinic

o Partners with clinic leadership to strive for optimal performance in quality, accurate risk adjustment, and affordability initiatives to improve long-term clinical outcomes while lowering the total cost of care

o Assess and coordinate training needs o Lead and schedule meetings with clinics o Ensures clinic has all data and analytics to ensure success in patient care delivery o Communicates incentive program elements and achievements o Resolves and escalates concerns

• Performance o Delivery of monthly strategic packets o Attestation point of care tool delivery and tracking o Dashboard performance and incentive reporting o Coordinate MA marketing and growth o Care management service coordination o Updates clinics on new wrap around services

• Training/Education o Primary Care Provider (PCP), staff, and clinic administrator education on risk

adjustment, quality, and affordability o Event coordination o New provider onboarding and orientation o Portal training o Claims issues/processes

• Member Focus o Member eligibility issues/resolution o Wraparound services utilization, education, and tracking o Data and analytics

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What is the difference between commercial insurance and Medicare Advantage (MA)?

Commercial (FFS) Medicare Medicare Advantage

Part C

Administrator Private Company Federal Gvt Private Comp/Federal Gvt

Eligibility Anyone 65y and Older 65y and Older

Enrollment Open Enrollment/Spec Circumstances General/Open Enrollment Initial/General/Open Enrollment

Different Plan Types

Coverage Area Typically, In-Network/Service Area Anywhere in US

Most cases no referral for Spec. In-Network/Service Area

May need referral to Spec.

Premium Varies by Plan/Tier $148.50 + $42 + 143 = $333.50/m

(2021) ~$36 + $148.50 = $184.50/m (2021)

Deductible Varies by Plan/Tier $7550

Federal Max for 2021

Out of Pocket Varies by Plan/Tier No Limit Limit by Plan

may change each year

Co-Payment Varies by Plan/Tier Varies by Plan/Tier

Co-insurance ~20% ~20% ~20%

Hospital Coverage Yes Part A Part A

Medical Coverage Yes Part B ~$144.60 (2020) Part B ~$144.60 (2020)

Drug Coverage Varies by Plan/Tier Part D (optional ~$42) (2020) Usually Included

Ancillary Coverage Varies by Plan/Tier Plan F Medigap ~ $143 (2020) No Medigap Coverage

Dental Not Included Not Included May Include

Vision Not Included Not Included May Include

Hearing Not Included Not Included May Include

Other Coverage Hospice Care Routine Exams

Fitness Membership

Payment for Services

Fed Gov pays directly to provider Medicare pay fixed amt to Plan

Company, which then cover services

Absorbs Risk No Yes Yes

Patient Cost Higher Cost Lower Cost than FFS but more than

MA More Cost Effective

Health Screenings Yes Yes Yes

Health Management May be available Disease Maintenance

Available Yes

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What Services does OCN offer?

Does OCN utilize Optum Pay? OCN does not utilize Optum Pay. Medicare Advantage HMO plans that are managed by OCN utilize InstaMed. What is InstaMed? Instamed is the vendor we use for our OCN check run processing. It’s a platform that provides a better healthcare payment experience that connects consumers, providers, and payers for healthcare transactions. Instamed processes payments securely through electronic transactions. How frequently can patients have an Annual Wellness Visit (AWV)? An AWV is a stand-alone visit that covers a health risk assessment, family and medical history, health maintenance screening review and referrals for preventive screening. An AWV does NOT include any type of physical exam. Enrollees can have one AWV per calendar year. Please visit www.optumpnw.com for more information. What is an Annual Comprehensive Visit (ACV)? An Annual Comprehensive Visit (ACV) is generally described as a visit that involves all the elements of an AWV combined with a physical exam or an additional problem-related visit.

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What health plans are OCN delegated for Utilization Management (UM)?

Health Plan UM Managed by

Contact Information

UHC – Medicare Advantage (HMO) • AARP Medicare Complete

o Plan 1 o Plan 2 o Plan 3

OCN Phone: Fax:

877-836-6806 855-402-1684

UHC – Medicare Advantage (Dual) • Medicare Solutions Dual Complete

UHC Phone: 877-842-3210

Humana – Medicare Advantage (HMO) • Gold Plus Humana HMO-MAPD Plan

OCN Phone: Fax:

877-836-6806 855-402-1684

Humana – Medicare Advantage (PPO) • HumanaChoice PPO

Humana Website: Phone:

www.Humana.com 800-457-4708

Humana – Medicare Advantage (MMP) • Gold Plus – SNP-DE

OCN Phone: Fax:

877-836-6806 855-402-1684

Premera – Medicare Advantage (HMO) • Medicare Advantage (HMO-MAPD Plan) • Medicare Advantage Classic (HMO-MAPD Plan) • Medicare Advantage Classic Plus (HMO-MAPD Plan) • Soundpath Health Alpine (HMO-MA Only Plan) • Soundpath Health Peak + Rx (HMO-MAPD Plan) • Soundpath Health Sound + Rx (HMO-MAPD Plan) • Soundpath Health Charter + Rx (HMO-MAPD Plan)

OCN Phone: Fax:

877-836-6806 855-402-1684

UHC – Medicaid • Community Health Plan • SCHIP

NPN Phone: Fax:

877-836-6806 253-627-4708

http://www.humana.com/

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Where do we send our claims?

Medicare Advantage Plans Submit to Claims Submission Information United Healthcare HMO – MA

• AARP o Plan 1o Plan 2o Plan 3

OCN Electronic Claims: Clearing House: Paper Claims:

Payer ID# LIFE1 Optum 360 PO Box 30788 Salt Lake City, UT 84130-0788

Humana HMO • Gold Plus HMO (HMO-MAPD Plan)



Humana PPO • HumanaChoice PPO (PPO-MAPD Plan)• Humana Honor PPO (PPO-MA only Plan)

Humana Electronic Claims: Clearing House: Paper Claims:

Payer ID# LIFE1 Availity PO Box 14601 Lexington, KY 40512

Premera Blue Cross HMO • Medicare Advantage (HMO-MAPD Plan)• Medicare Advantage Classic (HMO-MAPD Plan)• Medicare Advantage Core (HMO-MAPD Plan)• Medicare Advantage Core Plus (HMO-MAPD Plan)• Alpine (HMO-MA Only Plan)• Peak + Rx (HMO-MAPD Plan)• Sound +Rx (HMO-MAPD Plan)• Charter + Rx (HMO-MAPD Plan)


Payer ID# LIFE1 See back of patient’s ID card

DSNP Submit to Claims Submission Information United Healthcare

• Dual Complete (HMO D-SNP Plan)UHC Electronic Claims:

Paper Claims: Payer ID#95959 See back of patient’s ID card

Humana • Gold Plus HMO (HMO-MAPD Plan)



Medicaid Submit to Claims Submission Information United Healthcare (Apple Health)

• Community Plan • SCHIP

NPN Electronic Claims: Clearing House: Paper Claims:


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List of common resources:

OCN Main Number General Information

8 a.m.-5 p.m., Monday-Friday Phone 877-836-6806 Fax 888-205-1128

OCN Resources https://professionals.optumcare.com/resources-clinicians.html Website Address https://www.optumcare.com/state-networks/locations/washington.htm l

Provider Portal https://professionals.optumcare.com/ portal-login.html Customer Service Eligibility, claims/auth status, General billing questions Prior Authorization Intake

8 a.m.-5 p.m., Monday-Friday Phone 877-836-6806 Fax 888-205-1128 Fax 855-402-1984

Claims Payer ID Claims Mailing Address Claim Issue Escalation (Please first contact the Service Center)

LIFE1 PO Box 30788 Salt Lake City, UT 84130-0788 [email protected]

Health Care Coordination Pre-authorization, hospital pre-notification Emergent admission, case management

8 a.m.-5 p.m., Monday-Friday Phone 877-836-6806 Fax 253-627-4708

OCN Directory Searches (Provider, Facilities)

http://www.optum.com/pnw

Credentialing Phone 253-682-4809 Fax 253-573-9511 [email protected]

Practice Support Advocates providersupport@optum pnw.com

Address (For claims mailing see address in ‘Claims’ section)

Send general information to: 17930 International Blvd, Suite 100 Seatac, WA 98188

https://professionals.optumcare.com/resources-clinicians.html

https://www.optumcare.com/state-networks/locations/washington.html

https://professionals.optumcare.com/portal-login.html

mailto:[email protected]





Welcome to Optum Care Network of WashingtonOptum Care Network of Washington is an Independent Physician Association with a local management team. This quick reference guide provides an overview of the key information you will need to care for Optum patients. You may also view the full Washington Provider Manual on our website at: optum.com/pnw.

Your practice advocate Each practice in our network is supported by a dedicated practice advocate who is your go-to resource. Contact [email protected] to get connected with your practice advocate.

Submitting a claim For electronic submissions, use payer ID: LIFE1 via Optum 360 clearinghouse. You can view the status of claims on the Optum Care Provider Center, our online provider portal.

OneHealthPort users will have access to the Optum Care Provider Center within OneHealthPort.

For all other users, Optum Care Provider Center can be accessed via professionals.optumcare.com/portal-login

For paper submissions, send to the following: Attention: Optum Care Network P.O. Box 30788 Salt Lake City, UT 84130-0788

Electronic funds transfer (EFT) Optum Care Network works exclusively with InstaMed as our free payer payments solution for providers.

Please register for free ERA/EFT: Online: Visit instamed.com/eraeft Call: 1-866-945-7990

Website Use our website to sign in to the Optum Care Provider Center, a tool that gives you access to eligibility, prior authorization, and claims information in real time. You’ll also find our referral lookup tool, important forms and many other resources.

OneHealthPort users will have access to the Optum Care Provider Center within OneHealthPort.

For all other users, Optum Care Provider Center can be accessed via professionals.optumcare.com/portal-login

Specialists and facilities For a complete directory of Optum Care Network specialists and facilities, please contact our service center or use the provider lookup tool on our website: optum.com/pnw

Optum Care Network Service CenterThe customer service team is available to assist Monday-Friday, 8 a.m. - 5 p.m., PT. at 1-877-836-6806. You may also fax inquiries to 1-888-205-1128.

Referrals Patients in a participating plan of Optum Care Network will need a referral from their Primary Care Provider (PCP) to see a specialist, except for the specialties listed below.

• Behavioral health• Chiropractic• Obstetrics and gynecology (OB/GYN)

Specialists who are not contracted with the Optum Care Network will require prior authorization. An authorization request form can be found on the Optum Care Provider Center and submitted online (via our website or OneHealthPort) or faxed to 1-855-402-1684.

Prior authorization Prior authorization is required for certain services based on the patient’s plan benefits. For more details, refer to the provider manual on the website at: optum.com/pnw

Urgent and routine prior authorization Phone: 1-877-836-6806 Fax: 1-855-402-1684

Prior authorizations can also be submitted online through the Optum Care Provider Center (see Website section).

Please contact the patient’s health plan directly for Part D prior authorizations. Part B prescription prior authorizations will follow the process above.

Medical management Optum Care Network medical management programs provide high touch care coordination within hospitals, skilled nursing facilities (SNFs), and patients’ homes. These programs work in collaboration with the patient, the family/support system, providers and key stakeholders to coordinate discharge, healthcare services, community resources and referrals to the appropriate next level of care.

Medical management request processTo refer patients to Optum Care Network medical management programs, call 1-253-627-4113 or complete a referral form and fax to 1-253-627-4708.

Medical management services Patients may be enrolled into medical management programs through several pathways. Optum Care Network utilizes risk stratification algorithms to identify patients and may invite patients to enroll post-acute stay or after diagnoses of certain conditions. Providers may also request medical management services for their patients. Optum Care Network will coordinate closely with providers for any patients enrolled into medical management programs.

Case management (general and complex) • Dedicated nurse case manager• In-person and telephonic support• Health goal development• Disease management education and medication review• Post-discharge follow-up• Licensed social workers can assist patients with financial

resources, housing, transportation, placement and mealassistance

Transition to home visits• Short-term case management follow-up post-discharge• Collaboration with health care providers• Support safe discharge until patient can return to seeing PCP• Coordination of transitional services and supports

Provider quick reference guide: Optum Care Network

continued on back ▶Version as of 12/30/20

Patient care resources The following resources are available to support patient care for patients who are enrolled in a participating health plan. Contact your practice advocate for more information.

Remote patient monitoring Vivify is a remote patient monitoring phone and device app that monitors patient symptoms and biometrics related to particular disease states or care processes. Patients enroll and are monitored by a centralized team of nurses. Patients are able to request immediate communication 24/7 with their nurse monitor via secure text, telephone or video chats.

Mobile urgent care visit DispatchHealth is a mobile acute care service that offers same day appointments for patients with the goal of preventing unnecessary visits to the emergency room and reducing avoidable hospital admissions and readmissions. Consider DispatchHealth for patients with an acute, not immediately life-threatening medical need who:

• Are unwilling or unable to come in• Have difficulty with transportation• May not come in otherwise

Snohomish County Direct Line: 1-425-372-5441 Pierce County Direct Line: 1-253-666-9459 For more information: dispatchhealth.com

Optum outreach support The Optum Outreach team supports practices in making outbound calls to schedule visits for Medicare Advantage patients who need to be seen. We offer concierge technical support for patients and robust reporting for providers.

Optum house calls Optum offers virtual or in-home assessments to capture chronic conditions and quality care gaps. There is no cost to the patient or provider. These visits supplement the annual wellness visit and care by the provider.

Participating plansExample ID cards

1. Participating health plan logo2. Payer ID3. Network name4. Plan name5. Provider services toll-free number6. Medical claims address

© 2020 Optum, Inc. All rights reserved. 3687130 10/20

PROVIDER USE ONLY

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Optum Care Network

17930 International Blvd.

Suite 1000

SeaTac, WA 98188

T: 1-877-836-6806

F: 1-888-205-1128

optum.com/pnw

January 4, 2021

Optum Care Network (OCN) has implemented a process to improve Care Coordination in your

counties. As of January 1, 2021, providers in these counties may refer their OCN patients to

their respective health plan contracted providers WITHOUT PRIOR AUTHORIZATION through

OCN (ie. UnitedHealthcare, Humana, and Premera contracted providers).

However, procedures/services on the OCN Prior Authorization List will continue to require prior

authorization for all sites of service. The OCN Prior Authorization List can be found at

www.optumpnw.com.

PHYSICIAN ALERT

DO NOT RECYCLE

Clark, Kitsap, Island, Skagit and Whatcom County Optum Care Network Providers with

OCN Medicare Advantage patients

http://www.optumpnw.com/

2021 Attestations

Attestation Background

Attestations are an important tool in managing a patient’s health and identifying known and potential conditions

affecting their health. To validate these conditions, we encourage providers to complete and submit attestation forms in

conjunction with your patients’ in‐person visits and video visits.

When are attestations eligible for reimbursement? • Eligible patients that are seen between Dates of Service 1/1/2021-12/31/2021• Completed Attestations are returned through 1/31/2022

How much is the reimbursement? • $200 for each completed Attestation for Date of Service in Q2&Q3• $100 for each completed Attestation for Date of Service in Q1&Q4

• 1 form per patient each quarter can be submitted for reimbursemento For 2021, a maximum of $600 can be earned, over four quarters

Completed attestation components: • Action is taken on at least one condition on the Attestationo This criteria will change 1/1/22, requiring ALL conditions to be addressed to qualify for payment

• Encounter date(s) of face‐to‐face or video visit are between 1/1/2021-12/31/2021 (Q1-Q4)

• Attestation is signed and dated (with provider credentials and a legible signature)• Supporting chart note documentation to validate attestation is provided

• Supporting chart note documentation must also include provider credentials and a legible signature

How should attestations be submitted? • Fax Completed Attestation and Progress Notes to: (844) 308-4239

• The first page should be the Attestation page with the barcode at the top• The provider progress note immediately follows the Attestation page with the barcode

• If submitting a packet of multiple attestations (Attestation + Progress Note) ensure the barcode attestation isthe first page for each new patient, serving as a separator between each patient

What else should I know? • Any visits provided through virtual telehealth must be documented as including video and audio communication

(telephone-only encounters are not eligible for reimbursement)

• The Attestation Barcode must be visible and free of printing defects, smudges, tears , or hole punches

• Providers should address each HCC/ICD-10 by appropriately marking “agree” or “disagree” to each condition on

the attestation form

• Supporting progress notes must include appropriate documentation to support the “agreed” diagnosis

Who do I contact if I have more questions? • Your Practice Engagement Manager or email: [email protected]

Optum Care Network

Provider Manual

2021

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Table of Contents

Welcome Letter ......................................................................................................................................... 3

Provider Manual Overview ........................................................................................................................ 4

Delegation Defined ................................................................................................................................... 4

Contact Information ................................................................................................................................... 5

Practice Engagement ................................................................................................................................ 6

Summary ............................................................................................................................................... 6

Practice Advocate Responsibilities ........................................................................................................ 6

Credentialing ............................................................................................................................................. 6

Providers Joining Your Practice ............................................................................................................. 7

Types of Providers Credentialed ............................................................................................................ 7

Facilities Adding Location(s) .................................................................................................................. 7

Types of Facilities Credentialed ............................................................................................................. 7

Sub-Delegation of Credentialing ............................................................................................................ 8

Recredentialing ..................................................................................................................................... 8

Corrective Action ................................................................................................................................... 8

Provider/Facility Rights .......................................................................................................................... 8

Changes to Your Practice/Facility .......................................................................................................... 9

Termination of Participation ................................................................................................................... 9

Closing your Practice ............................................................................................................................. 9

Contracting ............................................................................................................................................. 10

Delegation by Plan .............................................................................................................................. 10

Claims ..................................................................................................................................................... 10

Claims Submission .............................................................................................................................. 11

Reimbursement ................................................................................................................................... 11

Electronic Funds Transfer .................................................................................................................... 12

Charging Members .............................................................................................................................. 12

Clinical Claims Review ........................................................................................................................ 13

Releasing a Patient from your Practice ................................................................................................... 13

Patient Re-Assignment ........................................................................................................................... 13

Compliance ............................................................................................................................................. 13

Medicare Compliance Expectations and Training ................................................................................ 13

Reporting Misconduct .......................................................................................................................... 14

HIPAA Compliance .............................................................................................................................. 14

HIPAA Violation Reporting ............................................................................................................... 15

Exclusion Checks ................................................................................................................................ 15

Preclusion List Policy ........................................................................................................................... 15

Marketing Compliance ......................................................................................................................... 16

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Guide Updates .................................................................................................................................... 16

Population Health .................................................................................................................................... 16

Quality & Risk Adjustment ................................................................................................................... 16

What does this mean to your practice? ................................................................................................ 17

Risk Adjustment Factor ....................................................................................................................... 17

Coding and Documentation Ongoing Education .................................................................................. 17

What does this mean to your practice? ................................................................................................ 17

Opportunities and Services .................................................................................................................. 18

Provider Attestations ........................................................................................................................... 18

EMR Optimization................................................................................................................................ 18

Utilization Management ........................................................................................................................... 18

Referrals / Pre-Authorizations .............................................................................................................. 19

Physical Therapy ............................................................................................................................. 20

Women’s Health ............................................................................................................................... 20

Care Management .................................................................................................................................. 20

Behavioral Health .................................................................................................................................... 20

Identifying OCN Members/Patients ......................................................................................................... 21

Portal Access .......................................................................................................................................... 21

Summary ............................................................................................................................................. 21

User Access ........................................................................................................................................ 21

Frequently Asked Questions ................................................................................................................... 21

How do I check the status of a claim, authorization, or member eligibility? .......................................... 21

Does OCN pay claims using Electronic Funds Transfer (EFT)? ........................................................... 21

How do I check if my provider(s) or facility are currently credentialed/ contracted with OCN? ............. 22

How do I submit a prior authorization? ................................................................................................. 22

Appendix ................................................................................................................................................. 23

Prior Authorization List (PAL) 2021 ...................................................................................................... 24

Prior Authorization Request Form ........................................................................................................ 33

Medicare ID Card Samples .................................................................................................................. 34

Delegation by Plan .............................................................................................................................. 35

Behavioral Health – Plan Resources ................................................................................................... 36

Issue date: January 2021

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Welcome Letter

Dear Provider,

I am delighted you have chosen to become a participating provider with Optum Care Network of Washington. We view you as our partner in providing affordable, high-quality health care for our members.

Together, we will help people live their best lives. Our goal is to let you as a provider practice medicine first and foremost. Our value-based model lets you focus on patients and care for your wellbeing as well as theirs.

You will get the support of a health care industry leader while you remain independent and able to make your own decisions. You also get a national team of doctors connecting your care to the latest evidence-based breakthroughs. And you have the local resources of a collaborative support team always ready to help you and your patients.

This provider manual offers valuable information about the Optum Care Network of Washington and how to work most effectively with us. It will serve as a user-friendly reference guide and educational resource for both you and your staff.

Our secure provider portal is located on our home page. It is available for your convenience to verify eligibility, claims status, submit, and review prior authorization status, and medical inquiries.

The Optum Care Network of Washington staff will work collaboratively with you to create a positive experience for you, your staff, and our enrollees. Please feel free to contact them as needed.

We welcome your comments and suggestions regarding this manual.

Sincerely, Tiffany Sullivan President Optum Care Network of Washington

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Provider Manual Overview

This provider manual is an extension of your participation agreement. It includes important information for providers, facilities and practice staff regarding policies, procedures, claims submissions and adjudication requirements, and guidelines used to administer plans. This provider manual replaces and supersedes all previous versions.

As per your participation agreement, all providers and facilities are to comply with CMS and health plan policies and procedures, including, but not limited to those listed herein. Please refer to health plan provider manuals for specific policies and procedures when applicable.

As policies and procedures change, updates will be issued via e-newsletter and/or practice alert and will be incorporated into this electronic version of the provider manual.

Any requirements under applicable law, regulation or governmental agency guidance that are not expressly set forth in this provider manual shall be incorporated herein by this reference and shall apply to providers, facilities, health plans and/or company where applicable. Such laws and regulations, if more stringent, take precedence over this provider manual. Providers and facilities are responsible for complying with all applicable laws and regulations.

Delegation Defined

Delegation is the formal process or contract granting an enterprise authority to execute specific functions on behalf of an organization; in the case of Optum Care Network (OCN), it refers to health plans. Ultimately, the health plan is the responsible party. As the delegating party, the health plan must remain apprised of the delegate’s actions, ensuring adherence to compliance standards.

In full delegation, this translates to providing services on behalf of the aforementioned plans to credential providers, provide care management services, administer utilization management, and adjudicate claims. OCN has additional plan relationships that serve to delegate specific functions of health plan work. Please refer to the appendix for delegation by plan.

Please contact your Practice Advocate if you have additional questions.

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Contact Information

OCN Main Number 8 a.m.‒5 p.m., Monday‒Friday General Information Phone 877-836-6806

Fax 888-205-1128

OCN Resources https://professionals.optumcare.com/resources-clinicians.html

Website Address https://www.optumcare.com/state-networks/locations/washington.html


8 a.m.‒5 p.m., Monday‒Friday Phone 877-836-6806 Fax 888-205-1128 Fax 855-402-1684

LIFE1 PO Box 30788, Salt Lake City, UT 84130-0788 [email protected]

8 a.m.‒5 p.m., Monday‒Friday Phone 877-836-6806 Fax 253-627-4708


Phone 253-682-4809 Fax 253-573-9511 [email protected]

[email protected]

Send general information to: 17930 International Blvd, Suite 1000

Provider Portal

Customer Service

Eligibility, claims/auth status, General billing question Prior Authorization Intake

Claims Payer ID Claims Mailing Address Claims Issue Escalation (Please first contact the Service Center)

Health Care Coordination Pre-authorization, hospital pre-notification, emergent admission, case management

OCN Directory Searches (Provider, Facilities)

Credentialing

Practice Support Advocates

SeaTac, WA 98188










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Practice Engagement

Summary

Each OCN provider group is assigned a Practice Advocate. Your Practice Advocate, together with their network medical director partner, work to help you succeed in 5-Star quality, patient experience, risk adjustment, care management, affordability, contracting, and growth.

Practice Advocate Responsibilities

• Primary Single Point of Contact with Clinico Partners with clinic leadership to strive for optimal performance in quality, accurate risk

adjustment, and affordability initiatives to improve long-term clinical outcomes whilelowering the total cost of care

o Assess and coordinate training needso Lead and schedule meetings with clinicso Ensures clinic has all data and analytics to ensure success in patient care deliveryo Communicates incentive program elements and achievementso Resolves and escalates concerns

• Performanceo Delivery of monthly strategic packetso Attestation point of care tool delivery and trackingo Dashboard performance and incentive reportingo Coordinate MA marketing and growtho Care management service coordinationo Updates clinics on new wrap around services

• Training/Educationo Primary Care Provider (PCP), staff, and clinic administrator education on risk adjustment,

quality, and affordabilityo Event coordinationo New provider onboarding and orientationo Portal trainingo Claims issues/processes

• Member Focuso Member eligibility issues/resolutiono Wraparound services utilization, education, and trackingo Data and analytics

Credentialing

Credentialing refers to the process performed by OCN to verify and confirm that an applicant meets the established policy standards and qualifications for consideration in the OCN Network. There are currently no fees charged for credentialing. Upon completion of the credentialing process, each applicant is presented to the Credentials Committee, which is comprised of physicians of various specialties, for review and recommendation. A complete copy of the OCN credentials program manual may be provided upon request.

OCN performs credentialing activities on behalf of health plans for which a credentialing delegation agreement has been executed. Credentialing applies across all health plan lines of business. The information provided in the table below is subject to change.

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Health Plan/Carrier Providers/Facilities Credentialed

Humana All Providers All Facilities

Premera All Providers Ambulatory Surgery Centers Effective 5/1/2020 will include all Facilities

UnitedHealthcare All Providers All Facilities

Providers Joining Your Practice

Unless the practice has a credentialing sub-delegation arrangement in place with OCN, all providers joining an existing practice must complete the credentialing process. Until such time as the provider has successfully completed the credentialing process, claims may not be reimbursed appropriately and/or denied payment. Contact your Practice Advocate or OCN Credentialing at least 60 days prior to your new provider seeing patients to minimize any reduction or denial of payment.

Types of Providers Credentialed

OCN credentials the following provider types:

• MD

• DO

• DPM

• ARNP

• PA-C

• CNM

• RNFA

• OD

• PhD

• SUDP

• PharmD

• PsyD

• LMHC

• LMFT

• LSW

Facilities Adding Location(s)

Unless a credentialing sub-delegation arrangement is in place with OCN, all facility locations must complete the credentialing process. Until such time as the additional location has successfully completed the credentialing process, authorizations and claims payment may be delayed. Contact OCN Credentialing at least 60 days prior to your new location seeing patients to minimize any denial of authorization or reduction in payment.

Types of Facilities Credentialed

• Ambulatory Surgery Centers

• Behavioral Health (facility)

• Birthing Centers

• Chemical Dependency Treatment Centers

• Durable Medical Equipment

• Home Health

• Home Infusion Therapy

• Hospitals

• Independent Diagnostic Testing Facility

• Laboratories

• Radiology (except therapeutic/interventional radiologists who are credentialed individually)

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• Physical, Occupational or Speech Therapies

• Skilled Nursing Facilities

• Urgent Care Centers

Sub-Delegation of Credentialing

OCN may delegate specific credentialing and recredentialing responsibilities to practice entities. Determination of whether a practice can be delegated is dependent on the successful results of a pre-delegation audit and execution of a credentialing sub-delegation agreement. Contact OCN Credentialing for additional information regarding eligibility and qualification.

Recredentialing

The recredentialing cycle occurs every three (3) years for providers and facilities. Non-response or failure to return a completed recredentialing application(s) and supporting documentation may be considered a voluntary termination of participation unless otherwise determined by the Chief Medical Officer and/or Credentials Committee.

Exceptions to this may include active military assignment, maternity/paternity leave or sabbatical. Contact OCN credentialing for additional information.

Corrective Action

Should OCN determine a provider or facility has failed to meet performance expectations pertaining to quality of care, patient services or established performance or professional standards, a corrective action plan may be implemented.

If a corrective action is not satisfactorily resolved within the designated period, the Chief Medical Officer has authority to recommend extension of the corrective action plan or suspension/termination from network participation.

Providers/facilities who are suspended or terminated have the right to appeal. Where an appeal is not reversed, OCN will notify the National Practitioner Data Bank and network affiliated entities (health plans) as required by law and contractual agreements.

The OCN credentialing program manual may be available upon request for additional details regarding corrective action, suspensions, terminations, and appeals.

Provider/Facility Rights

Providers and facilities have the right to review information submitted in support of their credentialing application. However, this is limited to information obtained from any outside primary source such as malpractice insurance carriers, state license boards, and/or National Practitioner Data Bank (NPDB).

Providers and facilities have the right to correct erroneous information in the event credentialing information received from other sources conflicts with information provided by the provider or facility.

Provider and facilities have the right to appeal a decision made by the Chief Medical Officer and/or the OCN Credentials Committee.

For detailed information regarding your rights, you may request a copy of the OCN credentialing program manual.

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Changes to Your Practice/Facility

All changes to your practice or facility should be provided to OCN in accordance with the terms of your Participation Agreement or as soon as reasonably possible. This includes, but is not limited to:

• Change in address

• Change in ownership

• Change in Tax Identification Number (TIN)

• Additions

• Deletions

• Terminations

• Changes to licensure (actual or threatened) resulting in loss, suspension, or material limitation ofa provider’s license

• Changes to staff membership or clinical privileges at any hospital

• Changes to formal disciplinary action, if any

• Change to any malpractice action filed against or decided adversely to provider

All changes should be sent to [email protected] for processing. OCN credentialing will notify health plans on a monthly basis for those plans which OCN has a delegated credentialing agreement in place.

If a provider terminates from your practice, your provider agreement requires notification to OCN via email to [email protected] within 30 days of departure. You are required to inform OCN via e-mail to whom patients should be re-assigned to. For more information on this topic, please refer to the Patient Re-assignment section below.

Termination of Participation

Providers/facilities are contractually required to provide adequate notice of termination of network participation as this may impact patient care and your credentialing status with the health plans. Upon termination with the OCN Network, your credentialing will revert to being performed directly with the health plans. Clinics should plan accordingly to ensure no disruption in services for patients. Please refer to your provider or facility agreement.

Closing your Practice

Closing your practice due to retirement or business considerations is a complex undertaking. OCN would like to support you in locating resources for your transition and identifying actions needed. The process can be very different for primary care providers and specialists. Please utilize your resources with OCN by contacting your Practice Advocates to assist in planning the logistics. The table below provides a start in preparing for such a change.



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Considerations PCP Specialist

Notify OCN via letter or email to [email protected] with a copy of the patient notification letter

Letter notifying patients of change

Communicate how patients may obtain their records

Recommendations for new providers

How to contact the office during and after the transition

Communicate changes to non-OCN health plans

Instruct patients to contact the health plan regarding a PCP change

Close patient panel

Identify patients currently in care management

Provide access to medical records to OCN (current year)

Contracting

OCN’s Provider and Facility Participation Agreements allow OCN to contract with health plans as an arranger of care. Please refer to your agreement for specifics. Please refer to the Credentialing section to determine eligibility to participate.

OCN holds the following contracts:

• Humana Medicare Advantage (HMO and PPO)

• Premera Medicare Advantage

• AARP Medicare Advantage (through UnitedHealthcare)

This list is subject to change. Providers/facilities must also hold a direct contract with the health plan for participation and/or reimbursement purposes. Please refer to the Claims section, the Credentialing and Contracting Crosswalk in the appendix or contact your Practice Advocate for details.

For OCN attributed members, your OCN participation agreement will supersede your direct health plan agreement.

Delegation by Plan

Please see appendix for the Delegation by Plan matrix.

Claims

OCN is delegated to adjudicate and pay claims for some health plans. Providers and facilities are responsible for verifying patient eligibility, benefits and obtaining referrals/authorizations, if applicable, prior to services being rendered. Please refer to the table below.


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Medicare Advantage Plans Submit to Claims Submission Information

United Healthcare HMO - MA • AARP Medicare AdvantageComplete

o Plan 1 (HMO-MAPD Plan)o Plan 2 (HMO-MAPD Plan)o Plan 3 (HMO-MAPD Plan)o Walgreens (HMO-MAPD Plan)

OCN Electronic Claims: Payer ID# LIFE1 Clearing House: Optum 360 Paper Claims: PO Box 30788

Salt Lake City, UT 84130-0788




Humana PPO

• HumanaChoice PPO (PPO-MAPD Plan)• Humana Honor PPO (PPO-MA only Plan)

Humana Electronic Claims: Payer ID# 61101 Clearing House: Availity Paper Claims: PO Box 14601

Lexington, KY 40512

Premera Blue Cross HMO • Medicare Advantage (HMO-MAPD Plan)• Medicare Advantage Classic (HMO–MAPD

Plan)• Medicare Advantage Classic Plus (HMO-

MAPD Plan)• Medicare Advantage Core (HMO-MAPD

Plan)• Medicare Advantage Core Plus (HMO-MAPD

Plan)• Alpine (HMO-MA Only Plan)• Peak + Rx (HMO-MAPD Plan)• Sound + Rx (HMO-MAPD Plan)• Charter + Rx (HMO-MAPD Plan)



D-SNP Plans Submit to Claims Submission Information

United Healthcare

• Dual Complete (HMO D-SNP Plan)

UHC Electronic Claims: Payer ID# 95959 Paper Claims: See back of patient’s

ID card

Humana

• Gold Plus SNP-DE (HMO D-SNP Plan)



Claims Submission

Claims should be submitted electronically to LIFE1. Paper claims, though not preferred, can be mailed to:

OCN Paper Claims OCN Electronic Claims PO Box 30788 Payor ID#: LIFE1 Salt Lake City, UT 84130-0788 Clearinghouse: Optum 360

Reimbursement

Reimbursement for services is defined in your practice/facility participation agreement. However, your reimbursement is affected not only by the terms of your Agreement, but also the following:

• Patient’s eligibility at the time of the service.

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• Whether services provided are covered benefits under the patient’s health plan.

• Whether services are medically necessary as required by the patient’s health plan.

• Whether services were without prior approval/authorization, if authorization is required.

• Patient copayments, coinsurance, deductibles, and other cost-share amounts due from thepatient and coordination of benefits with third-party payors as applicable.

• Adjustments of payments based on coding edits described above.

All services must comply with all federal laws, rules, and regulations applicable to individuals or entities receiving federal funds, including without limitation Title VI of the Civil Rights Act of 1964, Age Discrimination Act of 1975, Americans with Disability Act, and Rehabilitation Act of 1973. Please refer to your Provider/Facility Agreement for additional terms.

Nothing contained in the agreement or provider manual are intended to be a financial incentive or payment which directly or indirectly acts as an inducement for providers/facilities to limit medically necessary services.

Electronic Funds Transfer

OCN supports claims payments via electronic remittance advice (ERA) and electronic funds transfer (EFT) via InstaMed. ERA/EFT is a convenient, paperless, and secure way to receive claim payments. Funds are deposited directly into your designated bank account and include the TRN Reassociation Trace Number, in accordance with CAQH CORE Phase III Operating Rules for HIPAA standard transactions.

If you have not already set up your InstaMed account, please go to https://register.instamed.com/eraeft to register or contact InstaMed Customer Service via telephone or email.

Tool Free Telephone:

(866) INSTAMED or (866) 467-8263

Email:

[email protected]

Help Portal:

https://help.instamed.com/providers/s/

Training Tools:

https://www.instamed.com/support/providers

Charging Members

Practices and facilities are responsible for verifying patient eligibility and benefits prior to services, including, but not limited to, obtaining authorization for services. Practices and facilities are responsible for the collection of copays, co-insurance and/or deductibles as applicable. Please refer to CMS guidelines for additional details.

Additionally, per your OCN participation agreement, practices and facilities shall not charge a Medicare Advantage patient for non-covered services under the patient’s plan unless the patient has received a pre-service organization determination notice of denial from OCN or health plan before any such services are rendered. Please refer to your participation agreement for complete language.

https://register.instamed.com/eraeft




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Clinical Claims Review

Clinical records may be requested for further review by our Clinical Claims Review (CCR) department in order to determine if a service is considered medically necessary. These determinations are based on review of the member's medical information that supports the need for a particular service. These determinations are based on standard medical necessity guidelines.

Releasing a Patient from your Practice

Please refer to health plan specific provider manuals for releasing a patient from your practice.

Patient Re-Assignment

Optum Care Network manages patients assigned to primary care providers (PCPs) for Humana Medicare Advantage HMO, AARP Medicare Advantage HMO through UnitedHealthcare (UHC MA), and Premera Medicare Advantage HMO. In some cases, patients may be assigned to your practice in error. When this occurs, the health plan must be notified, and assignment must be corrected in their system(s). Patients who have not been seen by your practice, but have been assigned to you should not be re-assigned to another primary care provider unless that patient has initiated the process. See also Population Health.

For Humana patients:

• Patients can call Humana customer service number on the back of their ID card to request adifferent PCP, or

• Complete a PCP change form and fax to Humana. See Appendix.

For UHC MA patients:

• Patients should call the UHC customer service number on the back of their ID card to request adifferent PCP.

For Premera MA patients:

• Patients should call the Premera customer service number on the back of their ID card to requesta different PCP.

Compliance

Medicare Compliance Expectations and Training

The Centers for Medicare and Medicaid Services (CMS) requires Medicare Advantage (MA) organizations and Part D plan sponsors to annually communicate specific compliance and Fraud, Waste and Abuse (FWA) requirements to their “first tier, downstream and related entities” (FDRs). FDRs include contracted physicians, health care professionals, facilities, and ancillary providers, as well as delegates, contractors, and related parties.

As a delegate that performs administrative or health care services, CMS and other federal or state regulators require that you and your employees meet certain FWA and general compliance requirements. You are expected to have an effective compliance program, which includes training and education to address Code of Conduct, Health Insurance Portability and Privacy (HIPPA), FWA and compliance knowledge. Optum Care Network requires that you and your employees be sufficiently trained to identify, prevent and report incidents of non-compliance and FWA. This includes temporary workers and

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volunteers, the CEO, senior administrators, or managers, and subdelegates who are involved in or responsible for the administration or delivery of MA or Part D benefits or services. We have general compliance training and FWA resources available at: https://www.unitedhealthgroup.com/suppliers/compliance-program/general-compliance.html.

What you need to do for FWA and general compliance training:

• Provide FWA and general compliance training to your employees and contractors who work onMA and Part D programs. Administer FWA and general compliance training annually and within90 days of hire for new employees.

• All contracted payers will send out an annual compliance review in which OCN compliance willbe required to review and affirm that all compliance areas are met. There may be times OCNcompliance will need proof of general compliance training, therefore be prepared to provide anannual attestation that includes:

o Establishment of a Code of Conduct and Compliance Policies and Procedures, oradoption of the Optum documents

o Proof of established new hire and annual compliance training requirements

• Confirmation there are no offshore arrangements that are not reported to Optum nor without acompleted CMS attestation.

Reporting Misconduct

If you identify compliance issues and/or potential fraud, waste or abuse, please report it to us immediately so we can investigate and respond appropriately. Please see the Reporting Misconduct section of the UnitedHealth Group Code of Conduct.

Part of our compliance program is to have open communication with our partners, providers, and teammates to ensure compliance with our code of conduct, policies and relevant laws. We all have a responsibility to report issues or ask questions. Please contact compliance to report suspected violations of our code of conduct, suspected fraud, waste, or abuse activities or to ask general compliance questions:

• Email compliance at: [email protected]

• File a confidential report with our compliance Hotline:o 1-800-455-4521 or at

https://secure.ethicspoint.com/domain/media/en/gui/13549/report.html

Reports may be made anonymously, where permitted by law at https://www.unitedhealthgroup.com/who-we-are/our-culture/ethics-integrity.html. Optum Care Network expressly prohibits retaliation if a report is made in good faith.

HIPAA Compliance

Federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulations apply to covered entities and business associates, defined as health plans, health care clearinghouses, and health care providers who conduct certain electronic transactions.

HIPAA is a set of statutes designed to improve the efficiency and effectiveness of the U.S. health care system:

• Title I: Establishes rules to "improve the portability and continuity of health insurance coverage"for workers when they change employers.

• Title II: Establishes rules to prevent health care fraud and abuse. Its "Administrative Simplification"section sets standards for enabling the electronic exchange of health information, and includesprovisions establishing rules for protecting the privacy and security of personal health information:

https://www.unitedhealthgroup.com/suppliers/compliance-program/general-compliance.html



https://www.unitedhealthgroup.com/who-we-are/our-culture/ethics-integrity.html


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o Privacy Rule: protects the privacy of individually identifiable personal health informationo Security Rule: defines national security standards for protecting electronic data that

contain protected health information (PHI)o Enforcement Rule: Empowers the Secretary of the U.S. Department of Health and Human

Services (HHS) to impose civil money penalties on entities that violate HIPAA ruleso Breach Notification Rule: Requires HIPAA covered entities and their business associates

to notify affected individuals, the HHS Secretary and (in certain circumstances) the mediafollowing any breaches of unsecured PHI

HIPAA Violation Reporting

It is the policy of Optum Care Network to notify health plans, where required, when there has been a breach in a HIPAA regulation. To report a potential HIPAA privacy violation or breach:

• Email: [email protected]

• Call: compliance hotline 1-800-455-4521 (Anonymous reporting available)o Web: https://secure.ethicspoint.com/domain/media/en/gui/13549/report.html

(Anonymous reporting available)

Exclusion Checks

You must review federal exclusion lists (HHS-OIG and GSA) and state exclusion lists, as applicable, prior to hiring/contracting with employees (including temporary workers and volunteers), the CEO, senior administrators, or managers, and any subdelegates who are involved in or responsible for the administration or delivery of MA plan sponsor and Part D benefits or services to make sure that none are excluded from participating in federal health care programs. You must continue to review the federal and state exclusion lists on a monthly basis thereafter. For more information or access to the publicly accessible excluded party online databases, please see the following links:

• Health and Human Services — office of the Inspector General OIG List of Excluded Individualsand Entities (LEIE) at oig.hhs.gov

• General Services Administration (GSA) System for Award Management at SAM.gov

What you need to do for exclusion checks:

• Review applicable exclusion lists as outlined above and maintain a record of exclusion checks for10 years. Documentation of the exclusion checks may be requested by Optum Care Network,plan sponsors or CMS to verify that checks were completed.

Preclusion List Policy

CMS has a preclusion list effective for claims with dates of service on or after January 1, 2020. The Preclusion List applies to both MA plans as well as Part D plans. The preclusion list includes a list of prescribers and individuals or entities who:

• Are revoked from Medicare, are under an active re-enrollment bar and CMS has determined thatthe underlying conduct that led to the revocation is detrimental to the best interests of theMedicare program; or

• Have engaged in behavior for which CMS could have revoked the prescriber, individual or entityto the extent possible if they had been enrolled in Medicare and that the underlying conduct thatwould have led to the revocation is detrimental to the best interests of the Medicare program.

• Have been convicted of a felony under federal or state law within the previous 10 years and thatCMS deems detrimental to the best interests of the Medicare program. Care providers receive aletter from CMS notifying them of their placement on the Preclusion List. They can appeal withCMS before the preclusion is effective. There is no opportunity to appeal with Optum CareNetwork.

CMS updates the preclusion list monthly and notifies MA and Part D plans of the claim rejection date, which is the date on which we reject or deny a care provider’s claims due to precluded status. Once the



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claim-rejection date is effective, a precluded care provider’s claims will no longer be paid, pharmacy claims will be rejected, and the care provider will be terminated from the Optum Care Network. Additionally, the precluded care provider must hold Medicare beneficiaries harmless from financial liability for services provided on or after the claim rejection.

Marketing Compliance

For the purposes of this provider manual, “marketing” includes any information, whether oral or written, that is intended to promote or educate current or prospective Medicare beneficiaries about any Medicare plans, products, or services. All contracted practices and facilities are required to comply with all current CMS regulations regarding marketing. As of January 2019, CMS has clarified that providers may interact with their patients regarding plan options when relevant to the course of treatment or at the patient’s request. A summary of the rules are as follows, however please refer to https://www.cms.gov/Regulations-and-Guidance/Regulations-and-Guidance.html for the most current and in-force information.

Guide Updates

Optum Care Network reserves the right to supplement this guide to ensure that its information and terms and conditions remain in compliance with all governing Center for Medicare and Medicaid Services (CMS) regulations and relevant federal and state laws. This guide will be amended as needed.

Population Health

OCN has developed programs and resources in concert with health plans to support your practice around population health management. These programs and resources include, but are not limited to, complex care management, quality, risk adjustment programs, clinical education, patient engagement, affordability, social determinants of health, and Electronic Medical Record (EMR) optimization. There are the following four guiding principles of the OCN population health program:

• Promoting activities that drive quality outcomes.

• Focusing on prevention and early detection of conditions which may negatively impact the health or wellbeing of individuals.

• Expanding team-based care to include the broader health care continuum.

• Improving clinical outcomes while lowering the total cost of care.

Quality & Risk Adjustment

OCN is committed to supporting our partners in delivering the highest quality of care. To that end, providers may be given the tools and resources to identify quality care gaps, understand best practices, outreach/engagement of patients to close quality care gaps, and tactical support for meeting requirements in accordance with Medicare’s quality standards. All contracted providers are required to allow OCN access to patient charts, for OCN-attributed patients, as part of supporting quality initiatives and clinical documentation accuracy. As an essential part of ensuring all data is captured and reported to health plans, OCN performs chart reviews through remote EMR access, fax, and onsite access to your practice. Data for only your OCN attributed patients is reviewed and processed. The chart abstraction and review process can capture documentation to close care gaps and potential coding trends, which contribute to incentive payment measurements under the Quality Incentive Program.

https://www.cms.gov/Regulations-and-Guidance/Regulations-and-Guidance.html


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What does this mean to your practice?

• OCN will deploy chart abstractors to facilitate the capture of clinical documentation to close qualitycare gaps; or

• OCN will work with your practice to collect records either directly via fax or EMR, or through athird party to facilitate accurate capture of quality care gaps and conditions.

• Practice Advocates will work with practices to provide education, consultation, and materials tohelp our providers improve their systems and processes to impact highest quality of care.

Risk Adjustment Factor

Risk Adjustment Factor (RAF) is a numeric measurement based on health conditions a patient has (specifically those that fall within a CMS-assigned Hierarchical Condition Category or HCC), as well as demographic factors such as Medicaid status, gender, age/disabled status and whether the patient lives in an institution (for 90 days or longer) or not.

RAF is a relative measure of probable costs to meet the healthcare needs of the individual. RAF is used by Centers for Medicare and Medicaid Services (CMS) to adjust capitation payments to payors and thus to OCN for each Medicare Advantage (MA) member. As such, complete and accurate reporting of patient data is critical.

CMS requires providers to identify and document all conditions that may fall within an HCC at least once, each calendar year at a qualified visit. Documentation in the patient’s medical record must support the presence of the condition and indicate the provider’s assessment and treatment plan. OCN supports an accurate RAF score for your practice through in-home assessments, chart review, outreach support, and attestation forms.

Coding and Documentation Ongoing Education

As more of our work and payment structures are measured by data, it is increasingly important that we educate and prepare ourselves and our systems to capture the complexity of the care that we provide. To support clinical documentation and an accurate picture of each patient’s health and RAF, OCN provides ongoing education for clinicians and staff as well as regular feedback through reporting and analytics.

OCN has a team to help each clinic stay up to date, so that they can provide the most accurate coding and documentation of each patient’s clinical status. Our educators will help providers with diagnostic coding issues, medical record review, documentation standards, and education opportunities that support this ever-changing work in healthcare. Additionally, OCN will provide ongoing education and information with industry coding changes as they relate to risk adjustment. OCN’s goal is to help promote the highest quality of care to our patients.


• OCN will provide clinical documentation education and resources to providers and clinic staff tosupport on-going development of Risk Adjustment coding and Quality metric recognition coding(CPT Category II).

• Our educators can evaluate documentation and coding behavior and identify recommendationsfor improvement.

• We will provide consultation and education to help our network partners improve their systemsand processes to ensure complete, accurate, and compliant Risk Adjustment and Qualityreporting.

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Opportunities and Services

• We will perform reviews of medical documentation to ensure that all offices capture chronic HCC (hierarchical condition categories) that would affect the risk adjustment reimbursement, and any subsequent shared savings.

• OCN also analyzes data from inpatient hospitalizations, diagnostic testing, outpatient procedures and services, home health care services, durable medical equipment, rehabilitative therapies, and pharmacy reviews for the possibility of chronic codes that have not been addressed in the calendar year.

• OCN will prepare feedback and training materials to educate providers and their staff on any audit outcomes and will help with accurate documentation procedures.

• OCN will communicate with providers and staff coding and documentation trends and help implement correct diagnosis reporting.

• OCN will perform routine audits of documentation and coding in accordance with compliance policies and procedures and communicate the results to the offices.

• We will follow up with written and verbal education regarding coding and compliance to physicians, clinical staff, and non-clinical staff. You will also be able to request OCN educators to come to your clinics and help with any coding or documenting issues.

• OCN educators will remain apprised of the latest guidelines and relay that information to the clinics and staff. We will provide any updates of new codes or coding issues. OCN will send emails with webinars, coding materials, and any other education needed.

Provider Attestations

In order to submit accurate documentation and coding, OCN provides a point of care tool for primary care providers, including:

• A living (continuously refreshed) presentation that displays suspected relevant gaps in care that have not been addressed in the current calendar year.

o Gaps in care include historical chronic conditions, suspected conditions, screenings, and quality measures.

o Providers determine which are valid and address the gap. o Serves as a guide to be used at each face-to-face encounter.

• Sources of data on an attestation: o Diagnoses, procedures, and results reported in prior years. o Diagnoses and results found by nurses or coders (or, in some cases, M.D.) performing a

chart review. o Data inferred from labs tests, medication fills, and CMS Return files.

EMR Optimization

OCN has a full-time EMR optimization specialist who can assist your practice in utilizing your system more efficiently to compliantly enhance data collection and reporting opportunities. For more information, contact your Practice Advocate.

Utilization Management

OCN Utilization Management (UM) team works in concert with PCPs, specialists, and ancillary providers of care around the appropriate and efficient use of healthcare resources. The UM team works collaboratively with discharge planners in hospitals and skilled nursing facilities to ensure positive patient outcomes. However, OCN is not delegated for Utilization Management for all plans. Please refer to the table below.

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Health Plan UM Managed by Contact Information

UHC – Medicare Advantage (HMO)

• AARP Medicare Complete o Plan 1 o Plan 2 o Plan 3

OCN Phone: 877-836-6806 Fax: 855-402-1684

UHC – Medicare Advantage (Dual)

• Medicare Solutions Dual Complete

UHC Phone: 877-842-3210

Humana – Medicare Advantage (HMO)

• Gold Plus HMO-MAPD Plan

OCN Phone: 877-836-6806 Fax: 855-402-1684

Humana – Medicare Advantage (PPO)

• HumanaChoice PPO

Humana www.Humana.com Phone: 800-457-4708

Humana – Medicare Advantage (MMP)

• Gold Plus – SNP-DE

OCN www.Humana.com Phone: 800-457-4708

Premera – Medicare Advantage (HMO)

• Medicare Advantage (HMO-MAPD Plan)

• Medicare Advantage Classic (HMO–MAPD Plan)

• Medicare Advantage Classic Plus (HMO-MAPD Plan)

• Soundpath Health Alpine (HMO-MA Only Plan)

• Soundpath Health Peak + Rx (HMO-MAPD Plan)

• Soundpath Health Sound + Rx (HMO-MAPD Plan)

• Soundpath Health Charter + Rx (HMO-MAPD Plan)

OCN Phone: 877-836-6806 Fax: 855-402-1684

Referrals / Pre-Authorizations

As a managed care network, patients assigned to us are required to use providers/facilities from within our network for care. Keeping services in-network works to minimize some administrative burden and keep costs contained. We have a diverse group of specialists and facilities within our network, but are continuously working to grow and expand our reach in the community. If your patient requires a specialist or facility that is not within the OCN Network, then we recommend that the specialist/facility is contracted with the patient’s health plan. If the specialist/facility is not contacted with the plan, prior authorization is required. The OCN and health plan prior authorization lists are subject to change. Updates to the lists will be provided to the network as needed. The most current prior authorization list can also be found on the OCN provider portal at: https://professionals.optumcare.com/portal-login.html.

In-Network (Office Visits) (Tier 1): OCN PCP to OCN specialist referrals do not require precertification OCN specialist to OCN specialist do not require precertification

Out of Network Referral (Tier 2): Requires prior authorization from OCN

Please note: Not all plans have out-of-network benefits.




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Physical Therapy

Please note that an authorization is not required for Humana MA HMO or United Healthcare MA and Community Plan (and Premera Medicare Advantage after 5/1/2020). However, there is a 24-visit limit for United Healthcare Community Plan (Medicaid) members.

Women’s Health

A referral from a PCP is not required for covered women’s health care services when the services are provided by a women’s health care provider. However, the member must self-refer within her contracted plan’s network. Female-related diagnosis, urinary tract infections and disorders of the breast will be allowed under women’s self-referral for women on an OCN plan. If you have further questions, please contact your Practice Advocate. If a provider falls outside of both tiers and you believe their inclusion in the network would be beneficial, please alert network development at OCN and we will research the opportunity. Please refer to the appendix for sample forms and additional information. Please see instructions on how to access Tapestry link to request authorization electronically via our provider portal logon https://professionals.optumcare.com/portal-login.html.

Care Management

OCN’s Care Management team consists of registered nurses, licensed mental health counselors, social workers, and LPN care coordinators. Primary care offices can refer patients with complex care needs by referral, but we also capture members in need of services from utilization management, pre-authorization trends, transitions of care (i.e., Hospital to Skilled Nursing), and members can also self-refer. Care Management has oversight of the following programs:

• Transition Management

• Complex Care Management (medical/behavioral health)

• Disease Management/Condition Support

• Emergency Department Reduction Program

• Behavioral Health For additional information, please contact your Practice Advocate.

Behavioral Health

OCN manages behavioral health authorizations and adjudicates claims for Humana MA HMO line of business only. Please refer to Behavioral Health Plan Resources in the appendix for additional information. Beginning in early 2021, additional behavioral health services will be available to network members. This will include comprehensive substance use disorder treatment, treatment services for severely mentally ill patients, mental health counseling and peer support. More information about these services and how to refer patients will be provided. Please contact Regional Manager of Behavioral Health and Community Partnerships, Melissa Haney MA, LMFT, CCM [email protected] 253-207-4346 for more information.



21

Identifying OCN Members/Patients

Health plans assign patients based on PCP selection. In most cases, an identifier can be found on the patient’s health plan identification card listing OCN as the “Provider Group” or by Payer ID (LIFE1). Please refer to the health plan identification card samples in the appendix. Additionally, providers and facilities should verify eligibility using the health plan’s portal.

Portal Access

Summary

The Optum Care Provider Center (OCPC) will be a secure, internet-based, customized experience for providers to care for their patients and our members. A one-stop shop that has claims and member insights, prior authorizations, quality, risk adjustment and affordability performance data. Providers will have enhanced decision-making tools to improve care and lower costs.

The OCPC will provide access to the following:

• Eligibility Status

• Claims Status

• Prior Authorization Status

• Prior Authorization Submission

• Attestation Review and Submission

• Secure Messaging with Optum Care Network Teams

User Access

To access the OCPC, providers will need to perform the following steps: Navigate to the portal website, located at https://professionals.optumcare.com/portal-login.html. (This is the same site you will use to logon once your registration is processed.)

• Complete the fields under the ‘Provider Registration – New User’ section. (The request will thenbe reviewed by an OCN system administrator.)

• Once account registration is approved, an e-mail will be sent to the provider with login informationand instructions.

• Logon to OCPC and finalize setup.

Providers who had accessed the Northwest Physicians Network OneHealthPort platform prior to 01/01/2021 may access OCPC via the Optum link in OneHealthPort.

Frequently Asked Questions

How do I check the status of a claim, authorization, or member eligibility?

Log on to https://professionals.optumcare.com/portal-login.html for claims status, authorizations, and member eligibility. If you are unable to locate the claim or authorization, please contact OCN’s contact center at 877-836-6806 Monday through Friday 8 a.m. – 5 p.m.

Does OCN pay claims using Electronic Funds Transfer (EFT)?

Yes, OCN utilizes InstaMed for electronic funds transfer (EFT) and electronic remittance advice (ERA). Funds are deposited directly into your designated bank account and include the TRN Reassociation



22

Trace Number, in accordance with CAQH CORE Phase III Operating Rules for HIPAA standard. To register, please go to www.instamed.com/eraeft. (For additional InstaMed information, please see the

Electronic Funds Transfer section above.)

How do I check if my provider(s) or facility are currently credentialed/ contracted with OCN?

Please go to http://www.optum.com/pnw. If you are unable to locate the provider(s) or facility and you believe that you are/should be listed in the directory, please contact OCN’s contact center at 877-836-6806, Monday through Friday 8 a.m. – 5 p.m., so that they may further research for you.

How do I submit a prior authorization?

Complete an authorization request form (available electronically on OCN’s website) with all member information, specialist and/or facility information and requested service information, including diagnosis (ICD0-10-CM), service or procedure (CPT or HCPCS) being requested. Alternative care (acupuncture, chiropractic, massage and naturopathic) may not be a benefit under the member’s plan and may require prior authorization from OCN or the health plan network. All completed request forms can be faxed to 855-402-1684 for outpatient authorizations, 253-627-4708 for inpatient authorizations, or submitted electronically via the OCPC. (For additional information on OCPC, please see the Portal Access section above.)

Please allow two days before calling or resubmitting referral requests.

http://www.instamed.com/eraeft


23

Appendix

24

Prior Authorization List (PAL) 2021

Care Network – Washington

We have created this reference guide to provide you with information about the Prior Authorization Protocols. You can verify whether a prior authorization is required, or initiate a request online or by phone.

• Go to OneHealthPort.com or http://www.optum.com/pnw.

• Call 1-877-836-6806 from 8 a.m. to 5 p.m. PST.

• Fax 1-855-402-1684

Note: The following Prior Authorization List is effective as of January 1, 2021.

Procedure and Services CPT or HCPCS Codes Bone Growth Stimulator

20974 20975 20979

Breast Reconstruction - Non-Mastectomy

11920 11921 11922 19316 19318

19324 19325 19328 19330 19340

19342 19350 19357 19361 19364

19366 19367 19368 19369 19370

19371 19380 19396 L8600

Cancer Supportive Care

J0897 J1442

J2505 J2820

Q5101 Q5108

Q5110 Q5111

Q5120

Cardiology 33206

33207 33208 33212 33213 33214 33221

33224 33225 33227 33228 33229 33230 33231

33240 33249 33262 33263 33264 33270

93350 93351 93452 93453 93454 93455

93456 93457 93458 93459 93460 93461

Cardiovascular 75710 75716 93653


25

Procedure and Services CPT or HCPCS Codes Chemotherapy J0640

J0641 J0642 J9000 J9015 J9017 J9019 J9020 J9022 J9023 J9025 J9027 J9030 J9032 J9033 J9034 J9035 J9036 J9039 J9040 J9041 J9042 J9043 J9044 J9045 J9047 J9050 J9055 J9057

J9060 J9065 J9070 J9098 J9100 J9118 J9119 J9120 J9130 J9145 J9150 J9151 J9153 J9155 J9160 J9165 J9171 J9173 J9175 J9176 J9177 J9178 J9179 J9181 J9185 J9190 J9198 J9200 J9201



J9351 J9352 J9354 J9355 J9356 J9357 J9358 J9360 J9370 J9371 J9390 J9395 J9400 J9600 J9999 Q2017 Q2043 Q2049 Q2050 Q5107 Q5112 Q5113 Q5114 Q5115 Q5116 Q5117 Q5118 Q5119

Cochlear Implants & Other Auditory Implants

69714 69715

69718 69930

L8614 L8619

L8690 L8691

L8692

26

Procedure and Services CPT or HCPCS Codes Cosmetic & Reconstructive Cosmetic procedures that change or improve physical appearance without significantly improving or restoring physiological function

11960 11971 15820 15821 15822 15823 15830 15847 17106 17107 17108 17999

21172 21175 21179 21180 21181 21182 21183 21184 21230 21235 21248 21249

21255 21256 21260 21261 21263 21267 21268 21275 21299 21740 21742 21743

28344 30540 30545 30560 30620 31295 31296 31297 31298 67900 67901

67902 67903 67904 67906 67908 67909 67912 67950 67961 67966 Q2026

Durable Medical Equipment (DME) – Regardless of Cost Power mobility/accessories devices and lymphedema pumps require prior authorization regardless of cost

K0861 K0862 K0863 K0864 K0869

K0870 K0871 K0877 K0878 K0879

K0880 K0884 K0885 K0886 K0890

K0891 K0898 E0466 E1230

E1239 E2310 E2311 E2321

27

Procedure and Services CPT or HCPCS Codes Durable Medical Equipment (DME) >$1000 Rental or purchase cost will exceed $1000 over 12-month period

E0170 E0193 E0194 E0246 E0277 E0300 E0302 E0304 E0316 E0328 E0329 E0350 E0373 E0459 E0462 E0465 E0483 E0603 E0616 E0617 E0618 E0635 E0636 E0639 E0640 E0692 E0693 E0694 E0700 E0710




E1634 E1635 E1636 E1637 E1639 E1699 E1812 K0020 K0037 K0039 K0044 K0046 K0047 K0050 K0051 K0056 K0065 K0072 K0073 K0098 K0105 K0108 K0455 K0609 K0730 K0743 K0744 K0745 K0746

28

Procedure and Services CPT or HCPCS Codes Gender Dysphoria 14000

14001 14041 15734 15738 15750 15757 15758 15775 15776 15780 15781

15782 15783 15788 15789 15792 15793 19303 21899 31599 31899 53410 53420

53425 53430 54125 54400 54401 54405 54408 54520 54660 54690 55175 55180

55866 55970 55980 56625 56800 56805 57106 57110 57291 57292 57295

57296 57335 57426 58661 58720 58940 64856 64892 64896 92507 92508

Hysterectomy – IP and OP

58150 58152 58180

58541 58542 58543

58544 58550 58552

58553 58554 58570

58571 58572 58573

Hysterectomy – IP Only 58260

58262 58263

58267 58270 58275

58280 58290

58291 58292

58293 58294

Injectable A9513

A9590 A9606 A9699 C9061 J0222 J0223

J0584 J0791 J0881 J0885 J0896 J1300 J1301

J1303 J1442 J1447 J1745 J2326 J3398 J3399

J7320 J7321 J7322 J7323 J7324 J7326

J7327 J7329 J7331 J7332 J7333 Q5121

Inpatient Admissions-Post Acute services

Acute Care Hospitals Acute Inpatient Rehabilitation Critical Access Hospitals Long-term Acute Care Hospitals Skilled Nursing Facilities

Non-Emergency Transport - Air

A0430 A0431 A0435 A0436

Orthognathic Surgery

21120 21121 21122 21123 21125 21127 21141

21142 21143 21145 21146 21147 21150 21151

21154 21155 21159 21160 21188 21193 21194

21195 21196 21198 21199 21206 21210 21215

21240 21242 21244 21245 21246 21247

29

Procedure and Services CPT or HCPCS Codes Orthopedic Spinal and Joint Surgeries

22100 22101 22102 22110 22112 22114 22206 22207 22210 22212 22214 22220 22222 22224 22532 22533 22548 22551 22554 22556 22558 22590 22595 22600

22610 22612 22630 22633 22800 22802 22804 22808 22810 22812 22818 22819 22830 22849 22850 22852 22855 22856 22861 22864 22865 22867 22869 22899

23470 23472 24360 24361 24362 24363 27120 27122 27125 27130 27132 27134 27137 27138 27412 27445 27446 27447 27486 27487 29866 29867 29868 29914

29915 29916 63001 63003 63005 63011 63012 63015 63016 63017 63020 63030 63040 63042 63045 63046 63047 63050 63051 63055 63056 63064 63075 63077

63081 63085 63087 63090 63101 63102 63170 63172 63173 63180 63182 63185 63190 63191 63194 63195 63196 63197 63198 63199 63200 0200T 0201T J7330

Out of Network Services A recommendation from a network physician or health care provider to a hospital, physician or other health care provider who is not contracted with Optum Care Network

30

Procedure and Services CPT or HCPCS Codes Orthotics - greater than $1000 L0112

L0140 L0150 L0170 L0200 L0220 L0452 L0462 L0464 L0466 L0468 L0480 L0482 L0484 L0486 L0622 L0623 L0624 L0629 L0631 L0632 L0634 L0636 L0638 L0700 L0710

L0810 L0820 L0830 L0859 L0999 L1000 L1001 L1005 L1200 L1300 L1310 L1499 L1630 L1640 L1680 L1685 L1700 L1710 L1720 L1730 L1755 L1834 L1844 L1904 L1920 L2000




Potentially Unproven (including experimental/investigational and/or linked services)

28890 36514

64405 64722

64744 66180

95965 95966

Private Duty Nursing T1000

31

Procedure and Services CPT or HCPCS Codes Prosthetics - greater than $1000 L5010

L5020 L5050 L5060 L5100 L5105 L5150 L5160 L5200 L5210 L5220 L5230 L5250 L5270 L5280 L5301 L5312 L5321 L5331 L5341 L5400 L5420 L5500 L5505 L5510 L5520 L5530 L5535 L5540 L5560 L5570 L5580 L5585 L5590 L5595 L5600

L5610 L5611 L5613 L5614 L5616 L5639 L5643 L5649 L5651 L5681 L5683 L5700 L5701 L5702 L5703 L5707 L5724 L5726 L5728 L5780 L5781 L5782 L5795 L5814 L5818 L5822 L5824 L5826 L5828 L5830 L5840 L5845 L5848 L5856 L5857 L5858




Radiation Therapies (IMRT, SRS, SBRT)

G0251 77385 77386

G6015 77371 77372

77373 G0173

G0251 G0339

G0340 G6016

PET/SPECT 78459 78491 78492 78608

78609 78811 78812 78813

78814 78815 78816 78071

78072 78451 78452

78469 78494 78803

32

Procedure and Services CPT or HCPCS Codes Radiology 76376

76377 78012 78013 78014 78015 78016 78018 78070 78075 78099 78102 78103 78104 78185 78195 78199 78201

78202 78215 78216 78226 78227 78230 78231 78232 78258 78261 78262 78264 78265 78266 78278 78282 78290 78291

78299 78300 78305 78306 78315 78399 78428 78445 78453 78454 78456 78457 78458 78466 78468 78472 78473 78481

78483 78496 78499 78579 78580 78582 78597 78598 78599 78600 78601 78605 78606 78610 78630 78635 78645 78650

78660 78699 78700 78701 78707 78708 78709 78740 78761 78799 78800 78801 78802 78804 78830 78831 78832 78999

Septoplasty/Rhinoplasty 30400

30410 30420 30430

30435 30450

30460 30462

Stimulators Bone, Spinal and Vagus

61850 61863 61864

61867 61868

61886 64555

E0747 E0748

E0749 E0760

Sleep Apnea Procedures 21685 41512 41530 41599 42145 Transplants 32850

32851 32852 32853 32854 32855 32856 33930 33933 33935 33940 33944 33945

38208 38209 38210 38212 38213 38214 38215 38232 38240 38241 38242 44132 44133

44135 44136 44137 44715 44720 44721 47133 47135 47140 47141 47142 47143 47144

47145 47146 47147 48551 48552 48554 50300 50320 50323 50325 50340 50360 50365

50370 50380 50547 0537T 0538T 0539T 0540T Q2041 Q2042 S2060 S2061 S2152

Vein Procedures 36473

36475 36478 37700

37718 37722 37780

33927 33928 33929 33975

33

Prior Authorization Request Form

34

Medicare ID Card Samples

United Healthcare MA-HMO

Humana MA- HMO

Premera MA – HMO

Humana MAPD HMO D-SNP

35

Delegation by Plan

Functional Areas Humana MA HMO

Premera MA HMO

AARP MA HMO (UHC)

Utilization Management x x x

Disease Management x

x

Case Management x x x

Case Management for Transplants

Care Transitions x x x

Concurrent Review Management x x x

Correspondence x x x

ER Notification Outreach x x x

Claims x x x

Credentialing Providers; All Facility Types

Providers and ASCs only

Providers; All Facility Types

Quality/MRA x x x

Behavioral Health/Substance Use x

DSNP x x

36

Behavioral Health – Plan Resources

United Healthcare Medicare Advantage https://provider.liveandworkwell.com/content/laww/providersearch/en/home.html?siteId=10275&lang=1 Enter patient zip code, on Provider Listing Page, select “Medicare” Behavioral Health Claims and Authorizations 866-673-6315 Humana Medicare Advantage Behavioral Health provider assistance 1-866-900-5021 - Non-patient facing number. 8 a.m. – 6 p.m., Eastern time. Patients may call the number on the back of their Humana member ID card. Behavioral Health Claims and Authorizations - OCN Utilization Management Premera Medicare Advantage Find a Behavioral Health provider https://www.premera.com/visitor/find-a-doctor or call the “mental health” phone number on the back of the member’s card Behavioral Health Claims and Authorizations 1-800-711-4577

https://provider.liveandworkwell.com/content/laww/providersearch/en/home.html?siteId=10275&lang=1

https://www.premera.com/visitor/find-a-doctor

1

Northwest Physicians Network WWW.NPNWA.NET | PO BOX 2117, TACOMA, WA 98101

Provider Manual

2021

2

Table of Contents

Provider Manual Overview .............................................................................................................................. 4

Introduction ..................................................................................................................................................... 4

Delegation Defined .......................................................................................................................................... 4

Contact Information ......................................................................................................................................... 5

Practice Engagement ...................................................................................................................................... 6

Summary ..................................................................................................................................................... 6

Practice Advocate Responsibilities .............................................................................................................. 6

Credentialing ................................................................................................................................................... 6

Providers Joining Your Practice ................................................................................................................... 7

Types of Providers Credentialed .................................................................................................................. 7

Facilities Adding Location(s) ........................................................................................................................ 7

Types of Facilities Credentialed ................................................................................................................... 7

Sub-Delegation of Credentialing .................................................................................................................. 8

Recredentialing ............................................................................................................................................ 8

Corrective Action ......................................................................................................................................... 8

Provider/Facility Rights ................................................................................................................................ 8

Changes to Your Practice/Facility ................................................................................................................ 8

Termination of Participation ......................................................................................................................... 9

Closing your Practice ................................................................................................................................... 9

Contracting .................................................................................................................................................... 10

Delegation by Plan..................................................................................................................................... 10

Rainier Health Network .......................................................................................................................... 10

Medicare Shared Savings Program (MSSP) .......................................................................................... 10


Claims ........................................................................................................................................................... 10

Claims Submission .................................................................................................................................... 10

Reimbursement ......................................................................................................................................... 11

Electronic Funds Transfer .......................................................................................................................... 11

Charging Members .................................................................................................................................... 12

Clinical Claims Review .............................................................................................................................. 12

Reconsiderations ....................................................................................................................................... 12

Overpayment Recovery Process ............................................................................................................... 12

Releasing a Patient from your Practice.......................................................................................................... 12

Patient Re-Assignment .................................................................................................................................. 12

Compliance ................................................................................................................................................... 13

Compliance Expectations and Training ...................................................................................................... 13

Reporting Misconduct ................................................................................................................................ 13

3

HIPAA Compliance .................................................................................................................................... 14

HIPAA Violation Reporting ..................................................................................................................... 14

Exclusion Checks ...................................................................................................................................... 14

Preclusion List Policy ................................................................................................................................. 14

Marketing Compliance ............................................................................................................................... 15

Guide Updates ........................................................................................................................................... 15

Population Health .......................................................................................................................................... 15

Quality ....................................................................................................................................................... 15

Coding and Documentation ....................................................................................................................... 16

What does this mean to your practice? ...................................................................................................... 16

EMR Optimization ...................................................................................................................................... 16

Utilization Management ................................................................................................................................. 16

Referrals / Pre-Authorizations .................................................................................................................... 16

Physical Therapy .................................................................................................................................... 17

Women’s Health ..................................................................................................................................... 17

Care Management ........................................................................................................................................ 17

Behavioral Health .......................................................................................................................................... 17

Identifying NPN Members/Patients ................................................................................................................ 18

Portal Access ................................................................................................................................................ 18

Summary ................................................................................................................................................... 18

User Access .............................................................................................................................................. 18

Frequently Asked Questions ......................................................................................................................... 18

How do I check the status of a claim, authorization, or member eligibility? ................................................ 18

Does NPN pay claims using Electronic Funds Transfer (EFT)? ................................................................. 19

How do I check if my provider(s) or facility are currently credentialed/contracted with NPN? ..................... 19

How do I submit a referral? ........................................................................................................................ 19

Appendix ....................................................................................................................................................... 20

Prior Authorization List (PAL) 2021 ............................................................................................................ 21

Prior Authorization Request Form .............................................................................................................. 30

Medicaid ID Card Sample .......................................................................................................................... 31


Behavioral Health – Plan Resources ......................................................................................................... 33

Issue date: January 2021

4

Provider Manual Overview

This provider manual is an extension of your participation agreement. It includes important information for providers, facilities and practice staff regarding policies, procedures, claims submissions and adjudication requirements, and guidelines used to administer plans. This provider manual replaces and supersedes all previous versions.

As per your participation agreement, all providers and facilities are to comply with health plan policies and procedures, including, but not limited to those listed herein. Please refer to health plan provider manuals for specific policies and procedures when applicable.

As policies and procedures change, updates will be issued via e-newsletter and/or Practice Alert and may be incorporated into the electronic version and subsequent paper versions of this provider manual.

Any requirements under applicable law, regulation or governmental agency guidance that are not expressly set forth in this provider manual shall be incorporated herein by this reference and shall apply to providers, facilities, health plans and/or Northwest Physicians Network (NPN) where applicable. Such laws and regulations, if more stringent, take precedence over this provider manual. Providers and facilities are responsible for complying with all applicable laws and regulations.

Introduction

NPN was founded in 1995 by a group of physicians who wanted to provide better, more coordinated care to their patients while retaining their autonomy. Since 1995, NPN has supported independent practices and has built a collaborative, connected network of primary, specialty, and ancillary care providers throughout Washington. Our network delivers quality care that is affordable for patients and profitable for practices.

Delegation Defined

Delegation is the formal process or contract granting an enterprise authority to execute specific functions on behalf of an organization; in the case of NPN it refers to health plans. Ultimately, the health plan is the responsible party. As the delegating party, the health plan must remain apprised of the delegate’s actions, ensuring adherence to compliance standards.

In full delegation, this translates to providing services on behalf of the aforementioned plans to credential providers, provide care management services, administer utilization management, and adjudicate claims. NPN has additional plan relationships that serve to delegate specific functions of health plan work. Please refer to the appendix for delegation by plan.

Please contact your Practice Advocate if you have additional questions.

5





8 a.m.‒5 p.m., Monday‒Friday Phone 877-836-6806 Fax 888-205-1128 Fax 855-402-1684

LIFE1 PO Box 30788, Salt Lake City, UT 84130-0788 [email protected]



Phone 253-682-4809 Fax 253-573-9511 [email protected]

[email protected]

Send general information to: 17930 International Blvd, Suite 1000

Contact Information

NPN Main Number General Information

NPN Resources

Website Address

Provider Portal

Customer Service

Eligibility, claims/auth status, General billing question Prior Authorization Intake

Claims Payer ID Claims Mailing Address Claims Issue Escalation (Please first contact the Service Center)

Health Care Coordination Pre-authorization, hospital pre-notification, emergent admission, case management

NPN Directory Searches (Provider, Facilities)

Credentialing

Practice Advocates

SeaTac, WA 98188









6

Practice Engagement

Summary

Each NPN provider group is assigned a Practice Advocate. A Practice Advocate, together with their dyad Network Medical Director, work to help clinics succeed in 5-Star quality, patient experience, risk adjustment, care management, affordability, contracting, and growth.

Practice Advocate Responsibilities

• Primary Single Point of Contact with Clinic o Partners with clinic leadership to strive for optimal performance in quality, accurate risk

adjustment, and affordability initiatives to improve long-term, clinical outcomes while lowering the total cost of care

o Assesses and coordinates training needs o Leads and schedules meetings with clinics o Ensures clinic has all data and analytics to ensure success in patient care delivery o Communicates incentive program elements and achievements o Resolves and escalates concerns

• Performance o Delivery of monthly strategic packets o Attestation point of care tool delivery and tracking o Dashboard performance and incentive reporting o Coordinate MA marketing and growth o Care management service coordination o Updates clinics on new wraparound services

• Training/Education o Primary Care Provider (PCP), staff, and clinic administrator education on risk adjustment,

quality, and affordability o Event coordination o New provider onboarding and orientation o Portal training o Claims issues/processes

• Member Focus o Member eligibility issues/resolution o Wraparound services utilization, education, and tracking o Data and analytics

Credentialing

Credentialing refers to the process performed by NPN to verify and confirm that an applicant meets the established policy standards and qualifications for consideration in the NPN network. There are currently no fees charged for credentialing. Upon completion of the credentialing process, each applicant is presented to the Credentials Committee, which is comprised of physicians of various specialties, for review and recommendation. A complete copy of the NPN credentials program manual may be provided upon request. NPN performs credentialing activities on behalf of health plans for which a credentialing delegation agreement has been executed. Credentialing applies across all health plan lines of business. The information provided in the table below is subject to change.

7

Health Plan/Carrier Line of Business Providers/Facilities

Credentialed

UnitedHealthcare Medicaid All providers All facilities

Providers Joining Your Practice

Unless the practice has a credentialing sub-delegation arrangement in place with NPN, all providers joining an existing practice must complete the credentialing process. Until such time as the provider has successfully completed the credentialing process, claims may not be reimbursed appropriately and/or denied payment. Contact your Practice Advocate or NPN Credentialing at least 60 days prior to your new provider seeing patients to minimize any reduction or denial of payment.

Types of Providers Credentialed

NPN credentials the following provider types:

• MD

• DO

• DPM

• ARNP

• PA-C

• CNM

• RNFA

• OD

• PhD

• SUDP

• PharmD

• PsyD

• LMHC

• LMFT

• LSW

Facilities Adding Location(s)

Unless a credentialing sub-delegation arrangement is in place with NPN, all facility locations must complete the credentialing process. Until such time as the additional location has successfully completed the credentialing process, authorizations and claims payment may be denied. Contact NPN Credentialing at least 60 days prior to your new location seeing patients to minimize any denial of authorization or reduction in payment.

Types of Facilities Credentialed

• Ambulatory Surgery Centers

• Behavioral Health (facility)

• Birthing Centers

• Chemical Dependency Treatment Centers

• Durable Medical Equipment

• Home Health

• Home Infusion Therapy

• Hospitals

• Independent Diagnostic Testing Facility

• Laboratories

• Radiology (except therapeutic/interventional radiologists who are credentialed individually)

• Physical, Occupational or Speech Therapies

• Skilled Nursing Facilities

• Urgent Care Centers

8

Sub-Delegation of Credentialing

NPN may delegate specific credentialing and recredentialing responsibilities to practice entities. Determination of whether a practice can be delegated is dependent on the successful results of a pre-delegation audit and execution of a credentialing sub-delegation agreement. Contact NPN Credentialing for additional information regarding eligibility and qualification.

Recredentialing

The recredentialing cycle occurs every three (3) years for providers and facilities. Non-response or failure to return a completed recredentialing application(s) and supporting documentation may be considered a voluntary termination of participation unless otherwise determined by the Chief Medical Officer and/or Credentials Committee. Exceptions to this may include active military assignment, maternity/paternity leave or sabbatical. Contact NPN Credentialing for additional information.

Corrective Action

Should NPN determine a provider or facility has failed to meet performance expectations pertaining to quality of care, patient services or established performance or professional standards, a corrective action plan may be implemented. If a corrective action is not satisfactorily resolved within the designated period, the Chief Medical Officer has authority to recommend extension of the corrective action plan or suspension/termination from network participation. Providers/facilities who are suspended or terminated have the right to appeal. Where an appeal is not reversed, NPN will notify the National Practitioner Data Bank and network affiliated entities (health plans) as required by law and contractual agreements. The NPN credentialing program manual may be available upon request for additional details regarding corrective action, suspensions, terminations, and appeals.

Provider/Facility Rights

Providers and facilities have the right to review information submitted in support of their credentialing application. However, this is limited to information obtained from any outside primary source such as malpractice insurance carriers, state license boards, and/or National Practitioner Data Bank (NPDB). Providers and facilities have the right to correct erroneous information in the event credentialing information received from other sources conflicts with information provided by the provider or facility. Provider and facilities have the right to appeal a decision made by the Chief Medical Officer and/or the NPN Credentials Committee. For detailed information regarding your rights, you may request a copy of the NPN credentialing program manual.

Changes to Your Practice/Facility

All changes to your practice or facility should be provided to NPN in accordance with the terms of your Participation Agreement or as soon as reasonably possible. This includes, but is not limited to:

• Change in address

• Change in ownership

9

• Change in Tax Identification Number (TIN)

• Additions

• Deletions

• Terminations

• Changes to licensure (actual or threatened) resulting in loss, suspension, or material limitation of a provider’s license

• Changes to staff membership or clinical privileges at any hospital

• Changes to formal disciplinary action, if any

• Change to any malpractice action filed against or decided adversely to provider

All changes should be sent to [email protected] for processing. NPN credentialing will notify health plans on a monthly basis for those plans which NPN has a delegated credentialing agreement in place. If a provider terminates from your practice, your provider agreement requires notification to NPN via email to [email protected] within 30 days of departure. You are required to inform NPN via e-mail to whom patients should be re-assigned to. For more information on this topic, please refer to the Patient Re-assignment section below.

Termination of Participation

Providers/facilities are contractually required to provide adequate notice of termination of network participation as this may impact patient care and your credentialing status with the health plans. Upon termination with the NPN network, your credentialing will revert to being performed directly with the health plans. Clinics should plan accordingly to ensure no disruption in services for patients. Please refer to your provider or facility agreement.

Closing your Practice

Closing your practice due to retirement or business considerations is a complex undertaking. NPN would like to support you in locating resources for your transition and identifying actions needed. The process can be very different for primary care providers and specialists. Please utilize your resources with NPN by contacting your Practice Advocates to assist in planning the logistics. The table below provides a start in preparing for such a change.

Considerations PCP Specialist

Notify NPN via letter or email to [email protected] with a copy of the patient notification letter

Letter notifying patients of change

Communicate how patients may obtain their records

Recommendations for new providers

How to contact the office during and after the transition

Communicate changes to non-NPN Health Plans

Instruct patients to contact the Health Plan regarding a PCP change

Close patient panel

Identify patient currently in Care Management

Provide access to medical records to NPN (current year)




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Contracting

NPN’s Provider and Facility Participation Agreements allow NPN to contract with health plans as an arranger of care. Please refer to your Agreement for specifics. Please refer to the Credentialing section to determine eligibility to participate. NPN holds the following contracts:

• United Healthcare Community Plan (Managed Medicaid) This list is subject to change. Provider/facility must also hold a direct contract with the health plan for participation and/or reimbursement purposes. Please refer to the Claims section, the Credentialing and Contracting Crosswalk in the Appendix or contact your Practice Advocate for details. For NPN attributed members, your NPN Participation Agreement will supersede your direct health plan agreement.

Delegation by Plan

Please see appendix for delegation by plan matrix.

Rainier Health Network

Rainier Health Network (RHN) is an Accountable Care Organization (ACO) owned by CHI Franciscan Health and not a health plan. NPN is a participating network provider in RHN and you are included as part of NPN’s network arrangement. Additionally, you will need to have underlying health plan contracts. Please refer to NPN Credentialing and Contracting Crosswalk in the appendix for further details or contact RHN directly at [email protected] or 253-428-8444.

Medicare Shared Savings Program (MSSP)

To participate in the RHN MSSP contract, you must sign an agreement directly with RHN specifically to participate in this program. NPN, as a network, does not participate, manage, or administer this plan. For more information or how to participate, please contract RHN directly at [email protected] or 253-428-8444.

Delegation by Plan

Please see appendix for the Delegation by Plan matrix.

Claims

NPN is delegated to adjudicate and pay claims for United Healthcare Apple Health. Providers and facilities are responsible for verifying patient eligibility, benefits and obtaining referrals/authorizations, if applicable, prior to services rendered.

Claims Submission

Claims should be submitted electronically to LIFE1. Paper claims, though not preferred, can be mailed to: NPN Claims c/o OCN

PO Box 30788 Salt Lake City, UT 84130-0788



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Medicaid Submit to Claims Submission Information

United Healthcare (Apple Health)

• Community Plan • SCHIP

NPN Electronic Claims: Payor ID# LIFE1 Clearing House: Optum360 Paper Claims: See address above.

Rainier Health Network • Aetna Whole Health • BCBS of Illinois (CHI Employee Plan) • Regence (CHI Employee Plan – Kitsap

only) • United Healthcare

Health plan as applicable

Refer to patient ID card for appropriate health plan claims submission information.

Reimbursement

Reimbursement for service terms is defined in your Practice/Facility Participation Agreement. However, your reimbursement is affected not only by the terms of your Agreement, but also the following:


• Whether services provided are covered services under the patient’s health plan.

• Whether services are medically necessary as required by the patient’s health plan.

• Whether services were without prior approval/authorization, if authorization is required.

• Coordination of benefits with third-party payors as applicable.

• Adjustments of payments based on coding edits described above. All services must comply with all federal and state laws, rules, and regulations applicable to individuals or entities receiving federal funds, including without limitation Title VI of the Civil Rights Act of 1964, Age Discrimination Act of 1975, Americans with Disability Act, and Rehabilitation Act of 1973. Please refer to your Provider/Facility Agreement for additional terms. Nothing contained in the Agreement or provider manual are intended to be a financial incentive or payment which directly or indirectly acts as an inducement for providers/facilities to limit medically necessary services.

Electronic Funds Transfer

NPN engages InstaMed to deliver claims payments via electronic remittance advice (ERA) and electronic funds transfer (EFT). ERA/EFT is a convenient, paperless, and secure way to receive claim payments. Funds are deposited directly into your designated bank account and include the TRN Reassociation Trace Number, in accordance with CAQH CORE Phase III Operating Rules for HIPAA standard transactions. If you have not already set up your InstaMed account, please go to https://register.instamed.com/eraeft to register or contact InstaMed Customer Service via telephone or email.

Tool Free Telephone:

(866) INSTAMED or (866) 467-8263

Email:

[email protected]

Help Portal:


Training Tools:


https://register.instamed.com/eraeft




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Charging Members

Practices and facilities are responsible for verifying patient eligibility and benefits prior to services, including, but not limited to, obtaining authorization for services. Please refer to WAC 284-170-421 regulations in your Participation Agreement for additional details. Additionally, per your NPN Participation Agreement, practices and facilities must align to the state regulations in reference to balance billing a Medicaid member. Please refer to WAC 182-502-0160 for more detailed information.

Clinical Claims Review

Clinical records may be requested for further review by our Clinical Claims Review (CCR) department in order to determine if a service is considered medically necessary. These determinations are based on review of the member's medical information that supports the need for a particular service. These determinations are based on standard medical necessity guidelines.

Reconsiderations

For reconsiderations and/or disputes, call Customer Service at 1-877-836-6806, or send a letter addressed to:

Disputes and Reconsiderations P.O. Box 30788


Overpayment Recovery Process

NPN will seek reimbursement from any entity, as appropriate, for claims that were overpaid. Please refer to RCW 48.43.600.

Releasing a Patient from your Practice

Please refer to health plan specific provider manuals for releasing a patient from your practice.

Patient Re-Assignment

NPN manages patients assigned to PCPs for United Healthcare managed Medicaid. In some cases, patients may be assigned to your practice in error. When this occurs, the health plan must be notified, and assignment must be corrected in their system(s). Patients who have not been seen by your practice, but have been assigned to you should not be re-assigned to another PCP unless that patient has initiated the process. See also Population Health. For UHC Medicaid patients:

• Patients can call the UHC customer service number on the back of their ID card to request a different PCP; or

• Complete a PCP change form and fax to UHC. See Appendix.

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Compliance

Compliance Expectations and Training

The Centers for Medicare and Medicaid Services (CMS) requires organizations to annually communicate specific compliance and Fraud, Waste, and Abuse (FWA) requirements to their “first tier, downstream and related entities” (FDRs). FDRs include contracted physicians, health care professionals, facilities, and ancillary providers, as well as delegates, contractors, and related parties. As a delegate that performs administrative or health care services, CMS and other federal or state regulators require that you and your employees meet certain FWA and general compliance requirements. You are expected to have an effective compliance program, which includes training and education to address Code of Conduct, Health Insurance Portability and Privacy (HIPPA), FWA and compliance knowledge. Optum Care Network (OCN) requires that you and your employees be sufficiently trained to identify, prevent, and report incidents of non-compliance and FWA. This includes temporary workers and volunteers, the CEO, senior administrators, or managers, and subdelegates who are involved in or responsible for the administration or delivery of Managed Medicaid benefits or services. We have general compliance training and FWA resources available at: https://www.unitedhealthgroup.com/suppliers/compliance-program/general-compliance.html. What you need to do for FWA and general compliance training:

• Provide FWA and general compliance training to your employees and contractors who work on Managed Medicare programs. Administer FWA and general compliance training annually and within 90 days of hire for new employees.

• All contracted payers will send out an annual compliance review in which OCN compliance will be required to review and affirm that all compliance areas are met. There may be times OCN compliance will need proof of general compliance training, therefore be prepared to provide an annual attestation that includes:

o Establishment of a Code of Conduct and Compliance Policies and Procedures, or adoption of the Optum documents

o Proof of established new hire and annual compliance training requirements

• Confirmation there are no offshore arrangements that are not reported to Optum nor without a completed CMS attestation.

Reporting Misconduct

If you identify compliance issues and/or potential fraud, waste, or abuse, please report it to us immediately so we can investigate and respond appropriately. Please see the Reporting Misconduct section of the UnitedHealth Group Code of Conduct. Part of our compliance program is to have open communication with our partners, providers, and teammates to ensure compliance with our code of conduct, policies, and relevant laws. We all have a responsibility to report issues or ask questions. Please contact compliance to report suspected violations of our code of conduct, suspected fraud, waste, or abuse activities or to ask general compliance questions:

• Email compliance at: [email protected]

• File a confidential report with our compliance Hotline: o 1-800-455-4521 or at

https://secure.ethicspoint.com/domain/media/en/gui/13549/report.html Reports may be made anonymously, where permitted by law at https://www.unitedhealthgroup.com/who-we-are/our-culture/ethics-integrity.html. OCN expressly prohibits retaliation if a report is made in good faith.

https://www.unitedhealthgroup.com/suppliers/compliance-program/general-compliance.html





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HIPAA Compliance

Federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulations apply to covered entities and business associates, defined as health plans, health care clearinghouses, and health care providers who conduct certain electronic transactions. HIPAA is a set of statutes designed to improve the efficiency and effectiveness of the U.S. health care system:

• Title I: Establishes rules to "improve the portability and continuity of health insurance coverage" for workers when they change employers.

• Title II: Establishes rules to prevent health care fraud and abuse. Its "Administrative Simplification" section sets standards for enabling the electronic exchange of health information, and includes provisions establishing rules for protecting the privacy and security of personal health information:

o Privacy Rule: protects the privacy of individually identifiable personal health information o Security Rule: defines national security standards for protecting electronic data that contain

protected health information (PHI) o Enforcement Rule: Empowers the Secretary of the U.S. Department of Health and Human

Services (HHS) to impose civil money penalties on entities that violate HIPAA rules o Breach Notification Rule: Requires HIPAA covered entities and their business associates to

notify affected individuals, the HHS Secretary and (in certain circumstances) the media following any breaches of unsecured PHI

HIPAA Violation Reporting

It is the policy of OCN to notify health plans, where required, when there has been a breach in a HIPAA regulation. To report a potential HIPAA privacy violation or breach:

• Email: [email protected]

• Call: compliance hotline 1-800-455-4521 (Anonymous reporting available) o Web: https://secure.ethicspoint.com/domain/media/en/gui/13549/report.html

(Anonymous reporting available)

Exclusion Checks

You must review federal exclusion lists (HHS-OIG and GSA) and state exclusion lists, as applicable, prior to hiring/contracting with employees (including temporary workers and volunteers), the CEO, senior administrators, or managers, and any subdelegates who are involved in or responsible for the administration or delivery of Managed Medicaid plan sponsors or services to make sure that none are excluded from participating in federal or state health care programs. You must continue to review the federal and state exclusion lists on a monthly basis thereafter. For more information or access to the publicly accessible excluded party online databases, please see the following links:

• Health and Human Services — office of the Inspector General OIG List of Excluded Individuals and Entities (LEIE) at oig.hhs.gov

• General Services Administration (GSA) System for Award Management at SAM.gov What you need to do for exclusion checks:

• Review applicable exclusion lists as outlined above and maintain a record of exclusion checks for 10 years. Documentation of the exclusion checks may be requested by OCN, plan sponsors or CMS to verify that checks were completed.

Preclusion List Policy

CMS has a preclusion list effective for claims with dates of service on or after January 1, 2020. The preclusion list includes a list of prescribers and individuals or entities who:



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• Are revoked from Medicaid, are under an active re-enrollment bar and CMS has determined that the underlying conduct that led to the revocation is detrimental to the best interests of the Medicaid program; or

• Have engaged in behavior for which CMS could have revoked the prescriber, individual or entity to the extent possible if they had been enrolled in Medicaid and that the underlying conduct that would have led to the revocation is detrimental to the best interests of the Medicaid program.

• Have been convicted of a felony under federal or state law within the previous 10 years and that CMS deems detrimental to the best interests of the Medicaid program. Care providers receive a letter from CMS notifying them of their placement on the Preclusion List. They can appeal with CMS before the preclusion is effective. There is no opportunity to appeal with OCN.

CMS updates the Preclusion List monthly and notifies the health plans of the claim rejection date, which is the date on which we reject or deny a care provider’s claims due to precluded status. Once the claim-rejection date is effective, a precluded care provider’s claims will no longer be paid, pharmacy claims will be rejected, and the care provider will be terminated from the OCN network. Additionally, the precluded care provider must hold Medicaid beneficiaries harmless from financial liability for services provided on or after the claim rejection.

Marketing Compliance

For the purposes of this provider manual, “marketing” includes any information, whether oral or written, that is intended to promote or educate current or prospective Medicaid beneficiaries about any Medicaid plans, products, or services. All contracted practices and facilities are required to comply with all current CMS regulations regarding marketing. As of January 2019, CMS has clarified that providers may interact with their patients regarding plan options when relevant to the course of treatment or at the patient’s request. A summary of the rules are as follows, however please refer to https://www.cms.gov/Regulations-and-Guidance/Regulations-and-Guidance.html for the most current and in-force information.

Guide Updates

NPN reserves the right to supplement this guide to ensure that its information and terms and conditions remain in compliance with all governing Center for Medicare and Medicaid Services (CMS) regulations and relevant federal and state laws. This guide will be amended as needed.

Population Health

NPN has developed programs and resources in concert with health plans to support your practice around population health management. These programs and resources include, but are not limited to, complex care management, quality, and electronic medical record (EMR) optimization. There are the following four guiding principles of the NPN population health program:

• Promoting activities that drive quality outcomes.

• Focusing on prevention and early detection of conditions which may negatively impact the health or wellbeing of individuals.

• Expanding team-based care to include the broader health care continuum.

• Improving clinical outcomes while lowering the total cost of care.

Quality

NPN is committed to supporting our partners in delivering the highest quality of care. To that end, providers may be given the tools and resources to identify quality care gaps, understand best practices,



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outreach/engagement of patients to close quality care gaps, and tactical support for meeting requirements in accordance with Medicaid’s quality standards. All contracted providers are required to allow NPN access to patient charts for NPN attributed patients as part of supporting quality initiatives. As an essential part of ensuring all data is captured and reported to health plans, NPN deploys Chart Abstractors whether to your practice or via remote access to your EMR. Only data for your NPN attributed patients is reviewed and processed. The chart abstraction process can capture documentation to close care gaps.

Coding and Documentation

Documentation, coding and ensuring compliance takes education, communication and understanding by all the members of your clinic staff. As more and more of our work and payments structures are measured by data, it has become increasingly important that we educate and prepare ourselves and our systems to capture the complexity of the work we do.

NPN has a team to help your clinic stay up to date and able to report. The Coding and Compliance Educator will help providers with diagnostic coding issues, medical record review, documentation standards, and education opportunities that support the ever-changing work in healthcare. NPN’s goal is to help promote the highest quality of care to our patients.


• NPN will provide coding knowledge to you as a provider and to your clinic staff to support on-going development of quality metric recognition coding (CPT Category II)

• Our Certified Professional Coder will evaluate documentation and coding behavior and identify recommendations for improvement.

• We will provide consultation and education to help our providers improve their systems to impact and quality reporting.

EMR Optimization

NPN has a full-time EMR Optimization Specialist who can assist your practice in utilizing your system more efficiently to maximize data collection and reporting opportunities. For more information, contact your Practice Advocate.

Utilization Management

NPN Utilization Management (UM) team works in concert with PCPs, specialists, and ancillary providers of care around the appropriate and efficient use of healthcare resources. The UM team works collaboratively with discharge planners in hospitals and skilled nursing facilities to ensure positive patient outcomes. However, NPN is not delegated for Utilization Management for all plans. Please refer to the table below:


UHC – Medicaid

• Community Plan

• SCHIP

NPN Phone: 877-836-6806 Fax: 253-627-4708


As a managed care network, patients assigned to us are required to use providers/facilities from within our network for care. Keeping services in-network works to minimize some administrative burden and keep costs

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contained. We have a diverse group of specialists and facilities within our network but are continuously working to grow and expand our reach in the community. If your patient requires a specialist or facility that is not within the NPN Network, then we recommend that the specialist/facility is contracted with the patient’s health plan. If the specialist/facility is not contracted with the plan, prior authorization is required. Note: Some plans may not have out-of-network benefits.

In-Network (Office Visits) (Tier 1): NPN PCP to NPN Specialist referrals do not require precertification NPN Specialist to NPN Specialist do not require precertification

Out of Network Referral (Tier 2): Requires prior authorization from NPN

Physical Therapy

There is a 24-visit limit for United Healthcare Community Plan (Medicaid) members.

Women’s Health

A referral from a PCP is not required for covered women’s health care services when the services are provided by a women’s health care provider. However, the member must self-refer within her contracted plan’s network. Female-related diagnosis, urinary tract infections and disorders of the breast will be allowed under women’s self-referral for women on an NPN plan. If you have further questions, please contact your Practice Advocate. If a provider falls outside of both tiers and you believe their inclusion in the network would be beneficial, please alert network development at NPN and we will research the opportunity. Please refer to the appendix for sample forms and additional information. Please see instructions on how to access Tapestry link to request authorization electronically via our provider portal logon https://professionals.optumcare.com/portal-login.html.

Care Management

NPN’s Care Management team consists of registered nurses, licensed mental health counselors, social workers, and LPN care coordinators. Primary care offices can refer patients with complex care needs by referral, but we also capture members in need of services from utilization management, pre-authorization trends, transitions of care (i.e., Hospital to Skilled Nursing), and members can also self-refer. Care Management has oversight of the following programs:

• Transition Management

• Complex Care Management (medical/behavioral health)

• Disease Management/Condition Support

• Emergency Department Reduction Program

• Behavioral Health For additional information, please contact your Practice Advocate.

Behavioral Health

NPN manages behavioral health authorizations and adjudicates claims for Humana MA HMO line of business only. Please refer to Behavioral Health Plan Resources in the Appendix for additional information. Beginning in early 2021, additional behavioral health services will be available to network members. This will include comprehensive substance use disorder treatment, treatment services for severely mentally ill patients,


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mental health counseling and peer support. More information about these services and how to refer patients will be provided. Please contact Regional Manager of Behavioral Health and Community Partnerships, Melissa Haney MA, LMFT, CCM [email protected] 253-207-4346 for more information.

Identifying NPN Members/Patients

Health plans assign patients based on PCP selection. In most cases, an identifier can be found on the patient’s health plan identification card listing NPN as the “Provider Group” or by Payer ID (LIFE1). Please refer to the health plan identification card samples in the appendix. Additionally, providers and facilities should verify eligibility using the health plan’s portal.

Portal Access

Summary

The Optum Care Provider Center (OCPC) will be a secure, internet-based, customized experience for providers to care for their patients and our members. A one-stop shop that has claims and member insights, prior authorizations, quality, risk adjustment and affordability performance data. Providers will have enhanced decision-making tools to improve care and lower costs. The OCPC will provide access to the following:

• Eligibility Status

• Claims Status

• Prior Authorization Status

• Prior Authorization Submission

• Attestation Review and Submission

• Secure Messaging with NPN Teams

User Access

To access the OCPC, providers will need to perform the following steps: Navigate to the portal website, located at https://professionals.optumcare.com/portal-login.html. (This is the same site you will use to logon once your registration is processed.)

• Complete the fields under the ‘Provider Registration – New User’ section. (The request will then be reviewed by an NPN system administrator.)

• Once account registration is approved, an e-mail will be sent to the provider with login information and instructions.

• Logon to OCPC and finalize setup. Providers who had accessed NPN’s OneHealthPort platform prior to 01/01/2021 may access OCPC via the Optum link in OneHealthPort.

Frequently Asked Questions

How do I check the status of a claim, authorization, or member eligibility?

Log on to https://professionals.optumcare.com/portal-login.html for claims status, authorizations, and member eligibility. If you are unable to locate the claim or authorization, please contact NPN’s Customer Service at 877-836-6806 Monday through Friday 8 a.m. – 5 p.m.




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Does NPN pay claims using Electronic Funds Transfer (EFT)?

Yes, NPN utilizes InstaMed for electronic funds transfer (EFT) and electronic remittance advice (ERA). Funds are deposited directly into your designated bank account and include the TRN Reassociation Trace Number, in accordance with CAQH CORE Phase III Operating Rules for HIPAA standard. To register, please go to www.instamed.com/eraeft. (For additional InstaMed information, please see the Electronic Funds Transfer section above.)

How do I check if my provider(s) or facility are currently credentialed/contracted with NPN?

Please go to http://www.optum.com/pnw. If you are unable to locate the provider(s) or facility and you believe that you are/should be listed in the directory, please contact NPN’s Customer Service at 877-836-6806, Monday through Friday 8 a.m.–5 p.m., so that they may further research for you.

How do I submit a referral?

Complete an authorization request form (available electronically on NPN’s website) with all member information, specialist and/or facility information and requested service information, including diagnosis (ICD0-10-CM), service or procedure (CPT or HCPCS) being requested. Alternative care (acupuncture, chiropractic, massage and naturopathic) may not be a benefit under the member’s plan and may require prior authorization from NPN or the health plan network. All completed request forms can be faxed to 855-402-1684 for outpatient authorizations, 253-627-4708 for inpatient authorizations, or submitted electronically via the OCPC (see the Portal Access section above, as

needed). Please allow 2 days before calling or resubmitting referral requests.

http://www.instamed.com/eraeft


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Appendix

21

Prior Authorization List (PAL) 2021

We have created this reference guide to provide you with information about the Prior Authorization Protocols. You can verify whether a prior authorization is required, or initiate a request online or by phone.

• Go to OneHealthPort.com or http://www.optum.com/pnw.

• Call 1-877-836-6806 from 8 a.m. to 5 p.m. PST

• Fax 1-855-402-1684

Note: The following Prior Authorization List is effective as of January 1, 2021.

Procedure and Services CPT or HCPCS Codes Bone Growth Stimulator

20974 20975 20979

Breast Reconstruction - Non-Mastectomy

11920 11921 11922 19316 19318

19324 19325 19328 19330 19340

19342 19350 19357 19361 19364

19366 19367 19368 19369 19370

19371 19380 19396 L8600

Cancer Supportive Care

J0897 J1442

J2505 J2820

Q5101 Q5108

Q5110 Q5111

Q5120

Cardiology 33206

33207 33208 33212 33213 33214 33221

33224 33225 33227 33228 33229 33230 33231

33240 33249 33262 33263 33264 33270

93350 93351 93452 93453 93454 93455

93456 93457 93458 93459 93460 93461



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Procedure and Services CPT or HCPCS Codes Chemotherapy J0640

J0641 J0642 J9000 J9015 J9017 J9019 J9020 J9022 J9023 J9025 J9027 J9030 J9032 J9033 J9034 J9035 J9036 J9039 J9040 J9041 J9042 J9043 J9044 J9045 J9047 J9050 J9055 J9057




J9351 J9352 J9354 J9355 J9356 J9357 J9358 J9360 J9370 J9371 J9390 J9395 J9400 J9600 J9999 Q2017 Q2043 Q2049 Q2050 Q5107 Q5112 Q5113 Q5114 Q5115 Q5116 Q5117 Q5118 Q5119

Cochlear Implants & Other Auditory Implants

69714 69715

69718 69930

L8614 L8619

L8690 L8691

L8692

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Procedure and Services CPT or HCPCS Codes Cosmetic & Reconstructive Cosmetic procedures that change or improve physical appearance without significantly improving or restoring physiological function

11960 11971 15820 15821 15822 15823 15830 15847 17106 17107 17108 17999

21172 21175 21179 21180 21181 21182 21183 21184 21230 21235 21248 21249

21255 21256 21260 21261 21263 21267 21268 21275 21299 21740 21742 21743

28344 30540 30545 30560 30620 31295 31296 31297 31298 67900 67901

67902 67903 67904 67906 67908 67909 67912 67950 67961 67966 Q2026

Durable Medical Equipment (DME) – Regardless of Cost Power mobility/accessories devices and lymphedema pumps require prior authorization regardless of cost

K0861 K0862 K0863 K0864 K0869

K0870 K0871 K0877 K0878 K0879

K0880 K0884 K0885 K0886 K0890

K0891 K0898 E0466 E1230

E1239 E2310 E2311 E2321

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E1634 E1635 E1636 E1637 E1639 E1699 E1812 K0020 K0037 K0039 K0044 K0046 K0047 K0050 K0051 K0056 K0065 K0072 K0073 K0098 K0105 K0108 K0455 K0609 K0730 K0743 K0744 K0745 K0746

25

Procedure and Services CPT or HCPCS Codes Gender Dysphoria 14000

14001 14041 15734 15738 15750 15757 15758 15775 15776 15780 15781

15782 15783 15788 15789 15792 15793 19303 21899 31599 31899 53410 53420

53425 53430 54125 54400 54401 54405 54408 54520 54660 54690 55175 55180

55866 55970 55980 56625 56800 56805 57106 57110 57291 57292 57295

57296 57335 57426 58661 58720 58940 64856 64892 64896 92507 92508

Hysterectomy – IP and OP

58150 58152 58180

58541 58542 58543

58544 58550 58552

58553 58554 58570

58571 58572 58573


58262 58263

58267 58270 58275

58280 58290

58291 58292

58293 58294

Injectable A9513

A9590 A9606 A9699 C9061 J0222 J0223

J0584 J0791 J0881 J0885 J0896 J1300 J1301

J1303 J1442 J1447 J1745 J2326 J3398 J3399

J7320 J7321 J7322 J7323 J7324 J7326

J7327 J7329 J7331 J7332 J7333 Q5121


Acute Care Hospitals Acute Inpatient Rehabilitation Critical Access Hospitals Long-term Acute Care Hospitals Skilled Nursing Facilities


A0430 A0431 A0435 A0436


21120 21121 21122 21123 21125 21127 21141

21142 21143 21145 21146 21147 21150 21151

21154 21155 21159 21160 21188 21193 21194

21195 21196 21198 21199 21206 21210 21215

21240 21242 21244 21245 21246 21247

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Procedure and Services CPT or HCPCS Codes Orthopedic Spinal and Joint Surgeries

22100 22101 22102 22110 22112 22114 22206 22207 22210 22212 22214 22220 22222 22224 22532 22533 22548 22551 22554 22556 22558 22590 22595 22600

22610 22612 22630 22633 22800 22802 22804 22808 22810 22812 22818 22819 22830 22849 22850 22852 22855 22856 22861 22864 22865 22867 22869 22899

23470 23472 24360 24361 24362 24363 27120 27122 27125 27130 27132 27134 27137 27138 27412 27445 27446 27447 27486 27487 29866 29867 29868 29914

29915 29916 63001 63003 63005 63011 63012 63015 63016 63017 63020 63030 63040 63042 63045 63046 63047 63050 63051 63055 63056 63064 63075 63077

63081 63085 63087 63090 63101 63102 63170 63172 63173 63180 63182 63185 63190 63191 63194 63195 63196 63197 63198 63199 63200 0200T 0201T J7330

Out of Network Services A recommendation from a network physician or health care provider to a hospital, physician or other health care provider who is not contracted with NPN

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Procedure and Services CPT or HCPCS Codes Orthotics - greater than $1000






Potentially Unproven (including experimental/investigational and/or linked services)

28890 36514

64405 64722

64744 66180

95965 95966

Private Duty Nursing T1000

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Procedure and Services CPT or HCPCS Codes Prosthetics - greater than $1000






Radiation Therapies (IMRT, SRS, SBRT)

G0251 77385 77386

G6015 77371 77372

77373 G0173

G0251 G0339

G0340 G6016

PET/SPECT 78459

78491 78492 78608

78609 78811 78812 78813

78814 78815 78816 78071

78072 78451 78452

78469 78494 78803

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Procedure and Services CPT or HCPCS Codes Radiology 76376

76377 78012 78013 78014 78015 78016 78018 78070 78075 78099 78102 78103 78104 78185 78195 78199 78201

78202 78215 78216 78226 78227 78230 78231 78232 78258 78261 78262 78264 78265 78266 78278 78282 78290 78291

78299 78300 78305 78306 78315 78399 78428 78445 78453 78454 78456 78457 78458 78466 78468 78472 78473 78481

78483 78496 78499 78579 78580 78582 78597 78598 78599 78600 78601 78605 78606 78610 78630 78635 78645 78650

78660 78699 78700 78701 78707 78708 78709 78740 78761 78799 78800 78801 78802 78804 78830 78831 78832 78999

Septoplasty/Rhinoplasty 30400

30410 30420 30430

30435 30450

30460 30462


61850 61863 61864

61867 61868

61886 64555

E0747 E0748

E0749 E0760


32851 32852 32853 32854 32855 32856 33930 33933 33935 33940 33944 33945

38208 38209 38210 38212 38213 38214 38215 38232 38240 38241 38242 44132 44133

44135 44136 44137 44715 44720 44721 47133 47135 47140 47141 47142 47143 47144

47145 47146 47147 48551 48552 48554 50300 50320 50323 50325 50340 50360 50365

50370 50380 50547 0537T 0538T 0539T 0540T Q2041 Q2042 S2060 S2061 S2152

Vein Procedures 36473

36475 36478 37700

37718 37722 37780

Ventricular Assist Device 33927 33928 33929 33975

30

Prior Authorization Request Form

31

Medicaid ID Card Sample

Health Plan – United Healthcare Community Plan/Apple Health

32

Delegation by Plan

Functional Areas UHC Medicaid FirstChoice

Health Network

Utilization Management x

Disease Management x

Case Management x

Case Management for Transplants

Care Transitions x

Concurrent Review Management x

Correspondence x

ER Notification Outreach x

Claims x

Credentialing Providers; All Facility Types

Providers only

Quality/MRA x

Behavioral Health/Substance Use

DSNP

33

Behavioral Health – Plan Resources

United Healthcare Community Plan (Medicaid) Find a Provider https://www.uhcprovider.com/en/find-a-provider-referral-directory.html In person and tele-mental health visits are available Behavioral Health Claims and Authorizations 1-877-542-9231

https://www.uhcprovider.com/en/find-a-provider-referral-directory.html

26

Optum Care Provider Center Washington User Guide


© 2020 Optum, Inc. All rights reserved.

For internal use only. Confidential and proprietary. Not for distribution.

Prior Authorization Management

Click Prior Auth Mgmt.

This will launch Prior Authorization Management tool (Tapestry).

For additional information, reference your Prior Authorization training materials to launch and use this feature.

Care Network – Washington We have created this reference guide to provide you with information about the Prior Authorization Protocols for Optum Care Network. You can verify whether prior authorization is required or initiate a request online, by fax or by phone:

• Go to OneHealthPort.com or OptumPNW.com• Fax 1.888.402.1684

• Call 1.855.836.6806 from 8 am to 5pm PST

Effective July 1, 2021

Procedure and Services CPT or HCPCS Codes Bone Growth Stimulator 20974 20975 20979

Breast Reconstruction - Non-

Mastectomy

11920

11921 11922 19316

19318

19324

19325 19328 19330

19340

19342

19350 19357 19361

19364

19366

19367 19368 19369

19370

19371

19380 19396 L8600

Cardiology 33206

33207 33208 33212 33213

33214 33221

33224

33225 33227 33228 33229

33230 33231

33240

33249 33262 33263 33264

33270

93350

93351 93452 93453 93454

93455

93456

93457 93458 93459 93460

93461


Cochlear Implants & Other Auditory

Implants

69714

69715

69718

69930

L8614

L8619

L8690

L8691

L8692

Cosmetic & Reconstructive Cosmetic procedures that change or improve physical appearance without significantly improving or restoring physiological function

11960

11971 15820 15821

15822 15823 15830 15847

17106 17107 17108

17999

21172

21175 21179 21180

21181 21182 21183 21184

21230 21235 21248

21249

21255

21256 21260 21261

21263 21267 21268 21275

21299 21740 21742

21743

28344

30540 30545 30560

30620 31295 31296 31297

31298 67900 67901

67902

67903 67904 67906

67908 67909 67912 67950

67961 67966 Q2026



Procedure and Services CPT or HCPCS Codes Durable Medical Equipment (DME) – Regardless of Cost Power mobility/accessories devices and lymphedema pumps require prior authorization regardless of cost

K0861 K0862 K0863

K0864 K0869

K0870 K0871 K0877

K0878 K0879

K0880 K0884 K0885

K0886 K0890

K0891 K0898 E0466

E1230

E1239 E2310 E2311

E2321

Medications C9399 C9449 J0178 J0179

J0567 J0640 J0641

J0642 J0897 J1096

J1428 J1429 J1446

J1492 J2503 J2505

J2820 J3490 J3590 J3999

J7311 J7312 J7313

J7314 J7318 J7325

J7328 J9000 J9015

J9017 J9019 J9020 J9022

J9023 J9025 J9027

J9030 J9032 J9033

J9034 J9035 J9036 J9039

J9040 J9041 J9042

J9043 J9044 J9045

J9047 J9050 J9055

J9057 J9060 J9065

J9070 J9098 J9100 J9118

J9119 J9120 J9130

J9145 J9150 J9151

J9153 J9155 J9160

J9165 J9171 J9173 J9175

J9176 J9177 J9178

J9179 J9181 J9185

J9190 J9198 J9200 J9201

J9202 J9203 J9204

J9205 J9206 J9207

J9208 J9209 J9210

J9211 J9212 J9213

J9214 J9215 J9216 J9217

J9218 J9225 J9226

J9228 J9229 J9230

J9245 J9246 J9250

J9260 J9261 J9262 J9263

J9264 J9266 J9267

J9268 J9269 J9270

J9271 J9280 J9285 J9293

J9295 J9299 J9301

J9302 J9303 J9305

J9306 J9307 J9308

J9309 J9311 J9312

J9313 J9315 J9320 J9325

J9328 J9330 J9340

J9351 J9352 J9354

J9355 J9356 J9357

J9358 J9360 J9370 J9371

J9390 J9395 J9400

J9600 J9999 Q2017

Q2043 Q2049 Q2050 Q5101

Q5103 Q5104 Q5107

Q5108 Q5110 Q5111

Q5112 Q5113 Q5114

Q5115 Q5116 Q5117

Q5118 Q5119 Q5120 Q5122



E0170 E0193 E0194

E0246 E0277 E0300

E0302 E0304 E0316 E0328

E0329 E0350 E0373

E0459 E0462 E0465

E0483 E0603 E0616

E0617 E0618 E0635

E0636 E0639 E0640 E0692

E0693 E0694 E0700

E0710

E0740 E0746 E0761

E0764 E0770 E0782

E0783 E0784 E0785 E0786

E0830 E0970 E0983

E0984 E0986 E0988

E1002 E1003 E1004

E1005 E1006 E1007

E1008 E1009 E1010 E1011

E1017 E1018 E1020

E1029

E1030 E1035 E1036

E1037 E1050 E1070

E1084 E1085 E1086 E1087

E1089 E1100 E1110

E1161 E1170 E1171

E1172 E1180 E1190

E1195 E1200 E1222

E1224 E1227 E1228 E1229

E1231 E1232 E1233

E1234

E1235 E1236 E1237

E1238 E1270 E1280

E1295 E1296 E1297 E1298

E1310 E1399 E1500

E1510 E1520 E1530

E1540 E1550 E1560

E1575 E1580 E1590

E1592 E1594 E1600 E1615

E1620 E1625 E1630

E1632

E1634 E1635 E1636

E1637 E1639 E1699

E1812 K0020 K0037 K0039

K0044 K0046 K0047

K0050 K0051 K0056

K0065 K0072 K0073

K0098 K0105 K0108

K0455 K0609 K0730 K0743

K0744 K0745 K0746

Gender Dysphoria 14000

14001 14041 15734

15738 15750 15757 15758

15775 15776 15780

15781

15782

15783 15788 15789

15792 15793 19303 21899

31599 31899 53410

53420

53425

53430 54125 54400

54401 54405 54408 54520

54660 54690 55175

55180

55866

55970 55980 56625

56800 56805 57106 57110

57291 57292 57295

57296

57335 57426 58661

58720 58940 64856 64892

64896 92507 92508


Procedure and Services CPT or HCPCS Codes Hysterectomy – IP and OP

58150 58152 58180

58541 58542 58543

58544 58550 58552

58553 58554 58570

58571 58572 58573


58262 58263

58267 58270 58275

58280 58290

58291 58292

58293 58294

Injectable A9513

A9590

A9606 A9699 C9061

J0222 J0223

J0584 J0791

J0881 J0885 J0896

J1300 J1301

J1303 J1442

J1447 J1745 J2326

J3398 J3399

J7320 J7321

J7322 J7323 J7324

J7326

J7327 J7329

J7331 J7332 J7333

Q5121


Acute Care Hospitals Acute Inpatient Rehabilitation Critical Access Hospitals

Long-term Acute Care Hospitals Skilled Nursing Facilities


A0430 A0431 A0435 A0436


21120

21121 21122 21123

21125 21127 21141

21142

21143 21145 21146

21147 21150 21151

21154

21155 21159 21160

21188 21193 21194

21195

21196 21198 21199

21206 21210 21215

21240

21242 21244 21245

21246 21247

Orthopedic Spinal and Joint Surgeries

22100 22101 22102

22110 22112 22114

22206 22207 22210

22212

22610 22612 22630

22633 22800 22802

22804 22808 22810

22812

23470 23472 24360

24361 24362 24363

27120 27122 27125

27130

29915 29916 63001

63003 63005 63011

63012 63015 63016

63017

63081 63085 63087

63090 63101 63102

63170 63172 63173

63180


22214

22220 22222 22224

22532 22533 22548 22551

22554 22556 22558

22590 22595 22600

22818

22819 22830 22849

22850 22852 22855 22856

22861 22864 22865

22867 22869 22899

27132

27134 27137 27138

27412 27445 27446 27447

27486 27487 29866

29867 29868 29914

63020

63030 63040 63042

63045 63046 63047 63050

63051 63055 63056

63064 63075 63077

63182

63185 63190 63191

63194 63195 63196 63197

63198 63199 63200

0200T 0201T J7330

Procedure and Services CPT or HCPCS Codes Out of Network Services A recommendation from a network physician or health care provider to a hospital, physician or other health care provider who isn’t contracted with Optum Care Network

Orthotics - greater than $1000

L0112 L0140 L0150 L0170

L0200 L0220 L0452

L0462 L0464 L0466

L0468 L0480 L0482

L0484 L0486 L0622

L0623 L0624 L0629 L0631

L0632 L0634 L0636

L0638 L0700

L0810 L0820 L0830 L0859

L0999 L1000 L1001

L1005 L1200 L1300

L1310 L1499 L1630

L1640 L1680 L1685

L1700 L1710 L1720 L1730

L1755 L1834 L1844

L1904 L1920

L2005 L2010 L2020 L2030

L2034 L2036 L2037

L2038 L2040 L2050

L2060 L2070 L2080

L2090 L2126 L2136

L2232 L2320 L2387 L2520

L2525 L2526 L2627

L2628 L2800

L3160 L3201 L3202 L3203

L3204 L3206 L3207

L3208 L3209 L3211

L3212 L3213 L3214

L3215 L3250 L3251

L3252 L3253 L3254 L3255

L3257 L3265 L3320

L3485 L3649

L3720 L3764 L3765 L3766

L3891 L3900 L3901

L3904 L3921 L3956

L3961 L3967 L3971

L3973 L3975 L3976

L3977 L3978 L4000 L4030

L4040 L4045 L4050

L4055 L4631


L0710 L2000 L2861 L3674

Procedure and Services CPT or HCPCS Codes Potentially Unproven (including experimental/investigational and/or linked services)

28890

36514

64405

64722

64744

66180

95965 95966

Private Duty Nursing T1000 Prosthetics - greater than $1000

L5010

L5020 L5050 L5060

L5100 L5105 L5150

L5160 L5200 L5210

L5220 L5230 L5250

L5270 L5280 L5301 L5312

L5321 L5331 L5341

L5400 L5420 L5500

L5505 L5510 L5520

L5530 L5535 L5540 L5560

L5570 L5580 L5585

L5590 L5595 L5600

L5610

L5611 L5613 L5614

L5616 L5639 L5643

L5649 L5651 L5681

L5683 L5700 L5701

L5702 L5703 L5707 L5724

L5726 L5728 L5780

L5781 L5782 L5795

L5814 L5818 L5822

L5824 L5826 L5828 L5830

L5840 L5845 L5848

L5856 L5857 L5858

L5930

L5960 L5961 L5966

L5968 L5973 L5979

L5980 L5981 L5987

L5988 L5990 L6000

L6010 L6020 L6026 L6050

L6055 L6100 L6110

L6120 L6130 L6200

L6205 L6250 L6300

L6310 L6320 L6350 L6360

L6370 L6380 L6382

L6384 L6400 L6450

L6500

L6550 L6570 L6580

L6582 L6584 L6586

L6588 L6590 L6621

L6624 L6638 L6646

L6648 L6693 L6696 L6697

L6707 L6709 L6712

L6713 L6714 L6715

L6721 L6722 L6880

L6881 L6882 L6883 L6884

L6885 L6895 L6900

L6905 L6910 L6920

L6925

L6930 L6935 L6940

L6945 L6950 L6955

L6960 L6965 L6970

L6975 L7007 L7008

L7009 L7040 L7045 L7170

L7180 L7181 L7185

L7186 L7190 L7191

L7499 L8035 L8039

L8041 L8042 L8043 L8044

L8049 L8499 L8505

L8604 L8609 L8699


Procedure and Services CPT or HCPCS Codes Radiation Therapies (IMRT, SRS, SBRT)

G0251 77385

77386

G6015 77371

77372

77373 G0173

G0251 G0339

G0340 G6016

PET/SPECT 78459

78491 78492 78608

78609

78811 78812 78813

78814

78815 78816 78071

78072

78451 78452

78469

78494 78803

Radiology 76376 76377 78012

78013 78014 78015

78016 78018 78070

78075 78099 78102

78103 78104 78185 78195

78199 78201

78202 78215 78216

78226 78227 78230

78231 78232 78258

78261 78262 78264

78265 78266 78278 78282

78290 78291

78299 78300 78305

78306 78315 78399

78428 78445 78453

78454 78456 78457

78458 78466 78468 78472

78473 78481

78483 78496 78499

78579 78580 78582

78597 78598 78599

78600 78601 78605

78606 78610 78630 78635

78645 78650

78660 78699 78700

78701 78707 78708

78709 78740 78761

78799 78800 78801

78802 78804 78830 78831

78832 78999

Septoplasty/Rhinoplasty 30400 30410

30420 30430

30435 30450

30460 30462


61850 61863 61864

61867 61868

61886 64555

E0747 E0748

E0749 E0760


32851 32852 32853

32854 32855 32856

33930

38208

38209 38210 38212

38213 38214 38215

38232

44135

44136 44137 44715

44720 44721 47133

47135

47145

47146 47147 48551

48552 48554 50300

50320

50370

50380 50547 0537T

0538T 0539T 0540T

Q2041


33933

33935 33940 33944

33945

38240

38241 38242 44132

44133

47140

47141 47142 47143

47144

50323

50325 50340 50360

50365

Q2042

S2060 S2061 S2152

Procedure and Services CPT or HCPCS Codes Vein Procedures 36473

36475

36478

37700

37718 37722 37780

Ventricular Assist Device

33927 33928 33929 33975

11

Medicare Advantage Plans Submit to Claims Submission Information

United Healthcare HMO - MA • AARP Medicare AdvantageComplete

o Plan 1 (HMO-MAPD Plan) o Plan 2 (HMO-MAPD Plan) o Plan 3 (HMO-MAPD Plan) o Walgreens (HMO-MAPD Plan)

OCN Electronic Claims: Payer ID# LIFE1 Clearing House: Optum 360 Paper Claims: PO Box 30788 Salt Lake City, UT 84130-0788



Humana PPO

• HumanaChoice PPO (PPO-MAPD Plan) • Humana Honor PPO (PPO-MA only Plan)

Humana Electronic Claims: Payer ID# 61101 Clearing House: Availity Paper Claims: PO Box 14601 Lexington, KY 40512

Premera Blue Cross HMO • Medicare Advantage (HMO-MAPD Plan) • Medicare Advantage Classic (HMO–MAPD

Plan) • Medicare Advantage Classic Plus (HMO-

MAPD Plan) • Medicare Advantage Core (HMO-MAPD

Plan) • Medicare Advantage Core Plus (HMO-MAPD

Plan) • Alpine (HMO-MA Only Plan) • Peak + Rx (HMO-MAPD Plan) • Sound + Rx (HMO-MAPD Plan) • Charter + Rx (HMO-MAPD Plan)


D-SNP Plans Submit to Claims Submission Information

United Healthcare

• Dual Complete (HMO D-SNP Plan)

UHC Electronic Claims: Payer ID# 95959 Paper Claims: See back of patient’s ID card

Humana

• Gold Plus SNP-DE (HMO D-SNP Plan)


Claims Submission

Claims should be submitted electronically to LIFE1. Paper claims, though not preferred, can be mailed to:

OCN Paper Claims OCN Electronic Claims PO Box 30788 Payor ID#: LIFE1

Salt Lake City, UT 84130-0788 Clearinghouse: Optum 360

Reimbursement

Reimbursement for services is defined in your practice/facility participation agreement. However, your reimbursement is affected not only by the terms of your Agreement, but also the following:


19


UHC – Medicare Advantage (HMO)

• AARP Medicare Complete o Plan 1 o Plan 2 o Plan 3

OCN Phone: 877-836-6806 Fax: 855-402-1684

UHC – Medicare Advantage (Dual)

• Medicare Solutions Dual Complete

UHC Phone: 877-842-3210

Humana – Medicare Advantage (HMO)

• Gold Plus HMO-MAPD Plan

OCN Phone: 877-836-6806 Fax: 855-402-1684

Humana – Medicare Advantage (PPO)

• HumanaChoice PPO

Humana www.Humana.com Phone: 800-457-4708

Humana – Medicare Advantage (MMP)

• Gold Plus – SNP-DE

OCN www.Humana.com Phone: 800-457-4708

Premera – Medicare Advantage (HMO)

• Medicare Advantage (HMO-MAPD Plan)

• Medicare Advantage Classic (HMO–MAPD Plan)

• Medicare Advantage Classic Plus (HMO-MAPD Plan)

• Soundpath Health Alpine (HMO-MA Only Plan)

• Soundpath Health Peak + Rx (HMO-MAPD Plan)

• Soundpath Health Sound + Rx (HMO-MAPD Plan)

• Soundpath Health Charter + Rx (HMO-MAPD Plan)

OCN Phone: 877-836-6806 Fax: 855-402-1684


As a managed care network, patients assigned to us are required to use providers/facilities from within our network for care. Keeping services in-network works to minimize some administrative burden and keep costs contained. We have a diverse group of specialists and facilities within our network, but are continuously working to grow and expand our reach in the community. If your patient requires a specialist or facility that is not within the OCN Network, then we recommend that the specialist/facility is contracted with the patient’s health plan. If the specialist/facility is not contacted with the plan, prior authorization is required. The OCN and health plan prior authorization lists are subject to change. Updates to the lists will be provided to the network as needed. The most current prior authorization list can also be found on the OCN provider portal at: https://professionals.optumcare.com/portal-login.html.

In-Network (Office Visits) (Tier 1): OCN PCP to OCN specialist referrals do not require precertification OCN specialist to OCN specialist do not require precertification

Out of Network Referral (Tier 2): Requires prior authorization from OCN

Please note: Not all plans have out-of-network benefits.




34

Medicare ID Card Samples

United Healthcare MA-HMO

Humana MA- HMO

Premera MA – HMO

Humana MAPD HMO D-SNP

3


Optum® is a trademark of Optum, Inc. All other trademarks are the property of their respective owners. Because we are continuously improving our products and services, Optum reserves the right to change specifications without prior notice. Optum is an equal opportunity employer. © 2020 Optum, Inc. All rights reserved.


Introduction

The Optum Care Provider Center is a comprehensive solution for network providers. Accessible through the web, providers have a view into their performance and patients through a fully integrated experience. Member & Claims Insights Provides a streamlined fully integrated experience for providers. Includes easy access to real time detailed views into patient’s claims, related health status, eligibility, and benefits. Prior Authorizations Providers are able to manage the patient’s care by creating prior authorization requests. Quality and Risk Data PCP’s are able to manage their patient’s quality and risk performance through the Alliance dashboard. This comprehensive view of risk and quality metrics allows providers to update and submit online attestations with supporting documentation.

4




Logging In

LOGGING IN VIA ONEHEALTHPORT.COM

Step 1: Go to https://www.onehealthport.com/ Step 2: Select Login under the Single Sign-On section.

Step 3: Select Optum Logo under Participating Sites.

Step 4: Select Login once you are on the Optum Care Provider Center page.

5




Step 5: Enter your OneHealthPort User Name and Password.

LOGGING IN VIA PROFESSIONALS.OPTUMCARE.COM Step 1: Go to https://professionals.optumcare.com/ Step 2: Select Login at the top right corner of your screen.

Step 3: Select Washington Login under Location

Step 4: Click Sign In

6




Step 5: Enter your One Healthcare ID and Password and click Sign In.

Note: If you do not have a One Healthcare ID please refer to the user registration guide.

You will receive an Access Code Notification email.

Step 6: Enter Access Code. Step 7: Click the checkbox in front of Skip this step when signing in because this device is personal or private. Step 8: Click Next.

7




Note: If you have multiple Tax IDs it will show all of the TINs and you will need to select an account; otherwise, it will take you right to the dashboard.

© 2020 Optum, Inc. All rights reserved. • optum.com

Want to learn more or ask questions about the provider portal, email or schedule a meeting.

Questions

Portal Checklist

Did you know the Optum Provider Portal can be used for each of these items below?

Member Search – ability to look up member eligibility, cost sharing and prior authorizations

Claims Search – access information on all claims submitted to Optum (LIFE1)

Claims Escalation – message the claims department directly with questions about a claim

Member Roster – view your member roster and export to Excel for easy viewing and sorting

Submit Prior Authorizations & Referrals – submit and monitor status, plus immediate approval for services that do not require a prior auth

Attestations – access via PCP Reporting and print or submit electronically

Provider Dashboard – quickly view status of attestations, new members, and a patient census

Provider Resources – many links to additional information, an easy one-stop-shop

Multiple TIN’s• For organizations that have

multiple TIN’s you must accesseach provider under the TIN they are attached to

• If the portal is being accessed via OHP the user must have their OHP user ID associated with all the TIN’s they need access to

Quick Tips• Recommended browsers:

Chrome, Edge, and IE (v11)• Access the portal via OHP• Click on headers to sort columns in Prior

Authorization Management & PCP Reporting• You can find the Prior Authorization List under

Provider Resources

Enter Name Here | Practice Advocate [email protected]

Provider Portal

http://www.optum.com/

Population Health Education Team

The Population Health Education Team is a resource available to TEC, OCN, and Polyclinic

providers offering support and training in the following areas:

• Introduction to population health and risk adjustment

• Chronic condition recognition, risk adjustment documentation, and coding princi-

ples:

• Diabetes with Chronic Complications (HCC-018)

• Protein-Calorie Malnutrition (HCC-021)

• Morbid Obesity (HCC-022)

• Endocrine and Metabolic Disorders (HCC-023)

• Coagulation Defects and Hematological Disorders (HCC-048)

• Depression (HCC-059)

• Neuropathy (HCC-075)

• Congestive Heart Failure (HCC-085)

• Specified Heart Arrhythmias (HCC-096)

• Vascular Disease (HCC-108)

• Chronic Obstructive Pulmonary Disease (HCC-111)

• Dementia (HCC-051, HCC-052)

• Substance Use Disorder (HCC-55)

• Disorders of Immunity (HCC-47)

• Overview of quality measures (breast cancer screening, functional status assess-

ment, colorectal cancer screening, comprehensive diabetes care measures, etc.)

• Practice and provider risk adjustment and quality data review/analysis

• Attestation/Clinovations workflow discussion and troubleshooting

Our program’s goal is to foster a warm, longitudinal coaching relationship with providers

and support them in all aspects of documentation, coding, and risk adjustment – key pillars

of a successful population health strategy. We are able to train in 1:1 or group settings and

can also provide education to medical assistants, coders, and other support staff.

OCN practices and providers can reach out to their OCN practice advocate to schedule a

training. TEC and Polyclinic providers can arrange a training through their clinic manager.

Consumer Assessment of Healthcare of Providers and Systems (CAHPS)

1

Topic CAHPS Familiar Phrases

Getting Needed Prescription Drugs

“I see you’re prescribed [name Rxs]. It’s important to us that you find it easy to get your medicines. Are you finding that to be the case?”

“Have you ever not filled a prescription or put it off because you could not afford it?”

Getting Needed Care “We want to be sure you are getting the care, tests, or treatments you need. Have

those things been easy for you?” “Is there anything else I can do for you? I have time.”

Getting Appointments & Care Quickly

“We understand the importance of getting needed care right away.” [When Doctor requested is not available] “Dr. X is a great doctor and as you can

imagine, this makes him/her popular. His/her current appointments are booking “#” weeks out. Would you like me to set you up to see one of our other excellent doctors and we can give you a call if Dr. X has a cancellation before then?”

“Thank you for waiting [name], we respect your time. The Doctor should be with you within 15 minutes. If it is going to be any longer I will stop by myself to check on you and give an update.”

“Is there anything else I can do for you? I have time.”

Overall Rating of Health Care Quality

“We are committed to providing you with the best health care possible. Was there anything you wanted to discuss further today? I have time.”

Care Coordination

“To provide the best care, I’m just going to take a minute to review your medical recordfor any new information like tests or prescriptions or visits to a specialist.”

“It’s important to us to manage your care well and make sure you are satisfied.” “I want to make sure I’ve explained everything in a way that’s easy to understand. Did

you have any other questions?”

Provider-specific Various Topics

“It’s important to me that I explain things in a way that’s easy to understand. If you have any questions at all, please ask me.”

“It’s important to me to listen carefully to you, I respect what you have to say. If you feel there are any important points I’ve missed please let me know.”

“Is there anything else you wanted to talk about today? I have time.” “To provide the best care, I’m just going to take/have taken a minute to review your

medical record for any new information like tests or prescriptions or visits to a specialist. It’s important to me to manage your care well and make sure you are satisfied.”

“I want to be the best doctor possible for you. Is there anything more you’d like to discuss before leaving? I have time?”

Patient-specific Various Topics

“Have you been having any trouble walking or climbing stairs?” “Have you been having any trouble dressing or bathing?” “Do you have any struggles doing errands alone?” “Getting your annual flu shot is important.” “Getting your pneumonia shots is important.”

2021 CAHPS survey season is March 4th through May 28th

Created by CPQ National Education Team. Approved 5/19/2021

Quality quick tips

Consumer Assessment of Healthcare of Providers and Systems (CAHPS): Overview

Updated: 4/2021

Why It Matters The Center for Medicare and Medicaid (CMS) uses this survey to understand patient’s evaluation of their providers, health care system, and prescription drug services. Due to the importance of patient experience to CMS, the CAHPS survey data collected based on services provided in 2021 are now worth 36% of the overall Medicare Star score, an increase of 10% over the prior year. More information about the survey can be found at https://www.ma-pdpcahps.org .

Description of the Survey A random sample of Medicare Advantage members is selected to participate in CMS’ Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey every year. The survey is sent to these patients by mail each March, and if they do not respond, they receive a follow-up phone call. Data collection is completed in May. Patient participation in the survey is voluntary. The CAHPS survey is administered by CMS-approved vendors, and the results are reported in aggregate to health plans to preserve patient anonymity. Aggregate survey results are also publicly reported. Some of the measures are increasing in weight from one to four stars. This will take effect with the survey administered in 2022.

Influence: Direct Impact QuestionsGetting Needed Care (GNC) (weight of 4)How easy was it to get:

• Appointments with specialists?• The care tests, or treatment you needed?

Getting Appointments & Care Quickly (GCQ) (weight of 4)How often were you:

• Able to get care as soon as you needed?• Able to get appointments for routine care at a doctor’s office?• Abel to be seen within 15 minutes of your appointment time?

Care Coordination (COC) (weight of 4)Did your personal doctor:

• Have your medical records or other information about your care?• Follow up to give you test results and et the test results as soon as

you needed them?• Talk with you about all the prescription medicines you were taking?• Manage your care among different providers and services?• Seem informed and up-to-date about the care your got from

specialists?

Flu Vaccine (weight of 1)• Have you had a flu shot since July 1 of last year?

Influence: Indirect Impact QuestionsGetting Needed Prescription Drugs (weight of 4)How easy was it to:

• Get the medicines your doctor prescribed?• Fill a prescription at a local pharmacy?• Fill prescriptions by mail?

Best Practices for Supporting Patient Experience

• Giving the best access to care by utilizing walk-ins, weekend appointments, nurse practitioners, etc.

• Reducing waiting time at appointments to less than 15 minutes – update patients with what to expect if there is a delay

• Promoting positive communications with patients

• Greeting patients and creating a positive experience from the moment the patient walks in

• Establishing rapport before addressing the reason for the visit – take a moment to personally connect with the patient

• Telling the patient that his/her medical records were reviewed before the visit and referencing them during the appointment.

• Discussing medications taken by the patient and validating that they are the right drugs.

• Incorporate personalized messages about their care

• Following up with test results, if applicable.

Resources:

https://www.ma-pdpcahps.org/en/

https://www.ahrq.gov/cahps/index.html

https://www.cdc.gov/flu/professionals/vaccination/prepare-practice-tools.htm

https://www.ma-pdpcahps.org/




Consumer Assessment of Healthcare of Providers and Systems (CAHPS) 2021 (cont.)

Overall Rating MeasuresOn a scale from 1 – 10, how would you rate your:

• Health Plan• Drug Plan• Health Care Quality

Familiar PhrasesThe words you choose directly influence your patients’ perception of the care they receive. Using ‘familiar phrases’ encourages patient engagement and timely feedback. These phrases correspond to the CAHPS survey questions and are designed to help patients remember the quality care they receive. Familiar phrases have also been shown to increase patient experience scores.

Consider using these phrases:• We can help you coordinate care between different doctors and facilities. Is there anything we can

do to help make connections for you?• When you need care right away, you can always call us. Do you know how to contactus?• Let’s discuss the medicines you are taking

Strategies for Success• Consider using the Annual Wellness Visit and/or first annual visit to ask how we are meeting

your patients’ needs• Let patients know that they may receive surveys from their health plan. Encourage patients

to complete these surveys• Consider extending hours and offering walk-in care to improve access to care when needed• Let the patient know that their medical records were reviewed at each visit• Discuss the medications taken by your patients at each office visit• Before the conclusion of visits, offer to schedule appointments for specialists or tests to

support access to care and ease of scheduling for the patient• Save scheduling slots to allow prioritization of urgent, same day appointments when care is

needed right away• New patients usually give low scores when responding to this survey. Make an extra effort to

ensure your new patients feel engaged and supported beginning with their first visit. Letthem know you have reviewed their past medical history

• Patients with Social Determinants of Health (SDoH) score significantly lower to this survey.Link these patients to the right resources

• When possible, sit next to the patient when talking to them as this has been shown toincrease patient satisfaction.

TelehealthVirtual visits are very different from in person visits. Here are some tips to promote positive patient experiences via telehealth:

• Convey your compassion and care via gestures, facial expressions, and language• Ensure your patient can hear and see you during the visit – eye contact is important• Think about positive virtual waiting room messaging. Let the patient know when to expect their

provider to join the call and give updates as needed• Communicate with your patient before the appointment to make sure he/she understands how a

telehealth appointment works• Help your patient install the telehealth app (if applicable)• Be on time for scheduled appointments.


2021 Quality Measures At-A-Glance

1

MEASURE NAME

AGE DESCRIPTION DOCUMENTATION TIPS

EXCLUSIONS CODING**

PREVENTION & SCREENING

Breast Cancer Screening (BCS)

50-74 The percentage of women who had a mammogram any time on or between October 1, 2019 and December 31, 2021 to screen for breast cancer

Biopsies, breast ultrasounds and MRIs do not count towardsthis measure

Documentation of the year (and month if occurred prior to 2020) it was completed as part of the patient's history

Hospice or Palliative Care in 2021

Advanced Illness w/Frailty, ISNP, LTI

Optional: Bilateral or Two Unilateral Mastectomies anytime during the history through 2021

Z90.11 – acquired absence of right breastZ90.12 – acquired absence of left breastZ90.13 – acquired absence of bilateral breastsCPT – Mammography 77061- 77063; 77065 -77067

Colorectal Cancer Screening (COL)

50-75 Those members who received oneor more of the following screenings:

Fecal occult blood test annually(2021)

FIT-DNA (Cologuard) every 3 years (2019 –2021)

Flexible Sigmoidoscopy every 5 years (2017 –2021)

CT Colonography every 5 years (2017-2021)

Colonoscopy every 10 years (2012 –2021)

Documentation of the specific test and date of the test in the patient’s history. A result is notrequired if this is documented in the patient’s health history.

Digital rectal exams or FOBT tests performed in an in-office setting are not compliant.

A FIT test is not the same as the FIT-DNA test.



Optional: Colorectal cancer or total colectomy at any time in the patient’s history through 2021

82270 – Hemoccult Slide, (gFOBT ) 82274 – Hemoccult Slide, (FIT) G0328 – Colorectal Cancer screening FOBT, immuno-chemical, 1-3 simultaneously G0464 – Colorectal Cancer screening; stool- based DNA and fecal occult 81528 – FIT- DNA Z85.038 – hx neoplasm Lg Intestine Z85.048 – hx neoplasm Rectum/Sigmoid Junct/Anus

Care for Older Adults (COA)-Advanced Care Planning

66 years and older

Evidence of a discussion with the patient, or designated surrogate, in 2021 with documentation that includes a plan (e.g., advance directives, actionable provider orders for life-support, living will) regarding preferences for resuscitation, life-sustaining treatment, and end-of-life care or notation that the patient previously executed an advance care plan (ACP)

Always document the date of service of ACP evidence

Simply asking the patient if he or she has an ACP and documenting 'no' will not meet criteria.

ACP assessment can be done via telephone.

Hospice services any time in 2021

1123F – ACP discussed/documented or surrogate in record1124F – ACP discussed/documented; no surrogate named, or no ACP provided 1157F – ACP or similar legal document present 1158F – ACP discussion documented 99483 – assessment of and care planning for a patient 99497– ACP including the explanation and discussion of advance directives Z66 – DNRS0257 - Counseling and discussion regarding ACP

2021 PQA Measure Changes

2

Care for Older Adults (COA)-Functional Status Assessment

66 years and older

Percentage of adults who had evidence of a functional status assessment (FSA) during 2021

Functional status assessment conducted in an acute inpatientsetting will not meet compliance

The FSA can be done via telephone

Standardized assessment tools can be used

If assessing manually, 4 iADLs or 5 ADLs must be assessed

“Incontinence' does not meet criteria for assessing toileting


1170F - Functional status assessedG0438 - Initial annual wellness visit; includes a personalized prevention plan of serviceG0439 - Subsequent annual wellness visit; includes a personalized prevention plan of service99483 -Comprehensive evaluation of new or existing patient with signs/symptoms of cognitive impairment

Care for Older Adults (COA)-Medication Review

66 years and older

Percentage of adults who had a medication review by a clinical pharmacist or prescribing practitioner with the presence of a medication list in the medical record in 2021

Must be done by a prescribing provider or clinical pharmacist

A medication list, signed and dated during 2021

Documentation that the medications aren’t tolerated does not meet compliance

A review of side effects for a single medication does not meet compliance

Medication reviewconducted in an acute inpatient setting willnot meet compliance.


1159F- Medication list documented 1160F- Review of all medications, including prescriptions, OTC’s, herbal therapies, and supplements) G8427- Eligible clinician attests they obtained, updated, or reviewed the patient’s current medications

90863, 99483, 99605, 99606 - Medication review CPT codes

99495, 99496 -Transitional Care Management Services (TCM) CPT codes.

Care for Older Adults (COA)-Pain Assessment

66 years and older

Percentage of adults who were assessed for pain during 2021

A pain assessment in an acute inpatient setting is not compliant

A pain management plan or pain treatment alone will notmeet compliance

Chest paint does notmeet compliance

A pain assessment related to a single body part (except chest pain) meets compliance

Date and notation of “no pain” meets compliance


1125F - Pain present, pain severity quantified

1126F - Pain not present, pain severity quantified

MEASURE NAME


EXCLUSIONS CODING

PREVENTION & SCREENING CONTINUTED


3

Controlling Blood Pressure (CBP)

18-85 Percentage of patients who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled (<140/90 mmHg) during 2021

BP must be the last of the year

If multiple BP measurementsoccur on the same date or are noted in the chart on the same date, take the lowest systolic and the lowest diastolic of the BP readings

Example from visit: BP 1: 138/96BP 2: 142/79Take: 138/79

Patient reported BP is acceptable only if taken by a digital device



Optional:Evidence of end-stage renal disease (ESRD), dialysis, nephrectomy or kidney transplant on or prior to December 31, 2021

Dx of pregnancy in 2021

Patients who had a non-acute inpatient admission during 2021

3074F - Most recent systolic BP < 130

3075F - Most recent systolic BP 130 to 139

3077F - Most recent systolic BP ≥ 140

3078F - Most recent diastolic BP < 80

3079F - Most recent diastolic BP 80 to 89

3080F - Most recent diastolic BP ≥ 90

Medication Adherence for Cholesterol

18 years and older

The percentage of individuals who met the Proportion of Days Covered (PDC) threshold of 80% for statins during the treatment period in 2021

Treatment period begins on the earliest prescription date through either the last day of enrollment during 2021, death, or the end of the 2021

The treatment period should be at least 91 days

Only pharmacy claims are used to identify and close care opportunities for this measure.

Supplemental data cannot be submitted for this measure

Patients must use their health plan ID card to capture a pharmacy claim

Patients receiving hospice any time during 2021

ESRD during 2021

Prescription fills are captured via pharmacy claims.

Only prescription fills processed with a patient’s health plan ID card can be used to measure a patient’s adherence to their medication

Avoid using samples

Avoid using manufacturer medication assistance programs

Medication Adherence for Hypertension

18 years and older

The percentage of individuals who met the Proportion of Days Covered (PDC) threshold of 80% for Renin Angiotensin System (RAS) Antagonists during the treatment period in 2021



Only pharmacy claims are used to identify and close care opportunities for this measure




ESRD during 2021

Any individual with ≥1 prescription claim for sacubitril/valsartan during the treatment period in 2021



Avoid using samples


CARDIOVASCULAR CONDITIONS

MEASURE NAME


EXCLUSIONS CODING


4

CARDIOVASCULAR CONDITIONS CONTINUED

MEASURE NAME


EXCLUSIONS CODING

DIABETES

Comprehensive Diabetes Care (CDC) A1C

18-75 The percentage of members with diabetes who's latest HbA1c in 2021 was controlled (<9.0%)

Notation of the most recent HbA1c screening and result performed in2021

A patient reported A1C is acceptable if collected by the PCP or managing specialist as part of the patient’s history

Home test results must be sent to the lab or providers office for analysis

Hospice or palliative care services during 2021.


Optional: Gestational or steroid-induced diabetes, ORPolycystic ovarian syndrome without a diabetes diagnosis in 2020 and 2021

3044F-Most recent A1c level <7.0%

3046F- Most recent A1c level >9.0%

3051F- Most recent hemoglobin A1c (HbA1c) level equal to or > 7.0% and <8.0%

3052F- Most recent hemoglobin A1c (HbA1c) level equal to or > 8.0% and <9.0%

Statin Therapy for Patients withCardiovascular Disease (SPC)

Male 21-75

Female40-75

The percentage of members who were identified as having clinical atherosclerotic cardiovascular disease and met the following criteria:

• Were dispensed at least one -moderate or -high intensity statin

• Complied with therapy at least 80% of the treatment period

Documentation of the patient's name, date of birth, medication name/dose/quantity and date it was dispensed

A picture of the patient’s prescription bottle

A pharmacy receipt of medication administration record is evidence to show medication was dispensed

Patients receiving hospice or palliative care services any time during 2021

Patients who experience any of the following in 2020 or 2021:

• Pregnancy• Invitro fertilization• Dispensed at least

one prescription for clomiphene

• ESRD or dialysis• Cirrhosis

Myalgia, myositis, myopathy, or rhabdomyolysis in 2021




Avoid using samples


Comprehensive Diabetes Care (CDC) Nephropathy

18-75 The percentage of patients with diabetes who had a nephropathy screening, monitoring test or evidence of nephropathy during 2021

Nephropathy screening-urine test for protein/albumin/micro-albumin with a date and result in 2021

Patient on ACE/ARB therapy in 2021

Documentation that the patient was seen by a nephrologist in 2021 or has a hx of a renal transplant, nephrectomy or other documentation of medical attention to nephropathy

Hospice or palliative care services during 2021


Optional: Gestational or steroid-induced diabetes OR Polycystic ovarian syndrome without a diabetes diagnosis in 2020 and 2021

Urine Protein Tests: 3060F, 3061F, 3062F

Nephropathy Treatment: 3066F, 4010F

ICD-10 codes:N18.4-CKD Stage 4

N18.5, N18.6, Z99.2-ESRD


5

Comprehensive Diabetes Care (CDC) Eye Exam

18-75 The percentage of patients with diabetes who had a retinal eye exam performed

A retinal or dilated eye exam completed or interpreted by an optometrist or ophthalmologist or artificial intelligence in2021

A negative retinal ordilated exam done by an optometrist or ophthalmologist in 2020

Bilateral eye enucleation or acquired absence of both eyes

Fundus photography can be utilized for the diabetic retinopathy exam if it’s read by an optometrist or ophthalmologist in the appropriate timeframe as stated above.

Hospice or palliative care services during 2021


Optional: Gestational or steroid-induced diabetes OR Polycystic ovarian syndrome without a diabetes diagnosis in 2020 and 2021

CPT: 65091, 65093, 65101, 65103, 65105,65110, 65112, 65114CPT Modifier: 50 Unilateral Eye Enucleation with abilateral modifier

CPT II: 2022F, 2024F, 2026-Diabetic Retinal Screening With EyeCare Professional

92229-Automated Eye Exam

DIABETES CONTINUED

MEASURE NAME


EXCLUSIONS CODING

Statin Use in Persons with Diabetes (SUPD)

40-75 The percentage of patients with diabetes who • Received statin therapy

Patients should be dispensed at least one any intensity statin


This measure can only be met by pharmacy claims

Any of the following in 2021:

Hospice End Stage Renal Disease Pregnancy Lactation Fertility Medication: 1 or more prescription claims Liver Disease Pre-diabetesPolycystic Ovary Syndrome (PCOS)

Rhabdomyolysis or Myopathy



Avoid using samples



6

DIABETES CONTINUED

MEASURE NAME


EXCLUSIONS CODING

Medication Adherence for Diabetes

18 years and older

Percentage of patients who met the Proportion of Days covered (PDC) threshold of 80 % for diabetes medications during the treatment period in 2021



Only pharmacy claims are used to identify and close care opportunities for this measure




End-Stage Renal Disease Diagnosis during 2021

Patients with one or more prescription claims for insulin during the treatment period



Avoid using samples


MUSCULOSKELETAL

Osteoporosis Management in Women who had a Fracture (OMW)

67-85 The percentage of female patients who suffered a fracture and who had a bone mineral density (BMD) test and/or prescription for a drug to treat osteoporosis within six months of the fracture

Fractures of fingers, toes, face & skull do notfall into this measure.

If the fracture resulted in an inpatient stay, a BMD test done during the stay or long-acting osteoporosis therapy administered during the stay will close the care opportunity

Notation of a BMD completed within 6 months post fracture and include a date/result

Patients receiving hospice or palliative care services any time during 2021

Patients who had a Bone Mineral Density test during 24 months prior to fracture

Patients who had osteoporosis therapy or a prescription to treat osteoporosis during 12 months prior to fracture


76977 - Peripheral site

77078 - CT axial skeleton

77080 - DXA axial skeleton 77081 - DXA appendicular skeleton

77085 - DXA axial skeleton, (e.g., hips, pelvis, spine), including vertebral fracture assessment; 77086 -Vertebral fracture assessment via dual-energy X-ray absorptiometry (DXA)

MEDICATION MANAGEMENT & CARE COORDINATION

Transitions of Care (TRC)-Medication Reconciliation Post Discharge

18 Years and Older

The percentage of acute or non-acute inpatient discharges for patients who had a medication reconciliation performed on the date of discharge through 30 days after discharge in 2021

Documentation of medication reconciliation can be done by a prescribing practitioner, clinical pharmacist or an RN

Outpatient record must include current medication list, notation the provider reconciled current medication list with discharge medications and documentation of recent hospital discharge.

Patients receiving hospice care services any time during 2021

CPT II code - 1111F-Discharge medications reconciled with current medication list in outpatient record

CPT codes - 99483, 99495, 99496-Post DC visit with moderate-high complexity of care

Updated by CPQ National Education Team 05//2021Approved April 08, 2021

Pharmacy Quality Alliance. February 2021. PQA Measure Manual.

HEDIS® MY2020/2021 Vol 2 Technical Specs

*Coding is informational only and does not guarantee payment**For more information about each of these measures, please refer to the Optum 2021 Quality Quick Tips (QQTs)

Quality quick tips

Comprehensive Diabetes Care-Eye (CDC-EYE) 2021 Commercial, Medicare, Medicaid

OverviewDiabetic retinopathy is the most common diabetic eye disease and a leading cause of blindness in American adults. Approximately 7.7 million people ages 40 and older, have diabetic retinopathy. This number is expected to reach 11 million people by 2030 and 14.5 million by 2050. As much as 95% of severe vision loss from diabetic retinopathy is preventable by early detection, timely treatment and appropriate follow up.

Description of MeasurePercentage of patients ages 18–75 with diabetes (Types 1 and 2) who had any one of the following:• Retinal or dilated eye exam by an optometrist or ophthalmologist in 2021• Negative retinal or dilated eye exam by an optometrist or ophthalmologist in the

year prior to 2021 (2020)• Bilateral eye enucleations any time during their history through Dec. 31, 2021NOTE: Unilateral eye enucleations still require the retinal or dilated eye exam as mentioned above for the remaining eye. NOTE: Both diabetic retinopathy and hypertensive retinopathy are considered positive findings.

ExclusionsRequired: Patients receiving hospice or palliative care services any time during 2021. Note: Supplemental and medical record data may not be used for the following required exclusions:• Patients 66 years of age and older as of December 31, 2021 who meet either of

the following: enrolled in an Institutional SNP (I-SNP) or living long-term in an institution (as identified by the LTI flag in the CMS Monthly File) any time during 2021

• Patients 66 years of age and older as of December 31 , 2021 with frailty diagnosis in 2021 and advanced illness diagnosis in 2020 or 2021.

Optional*: Gestational or steroid-induced diabetes or polycystic ovarian syndrome without a diabetes diagnosis in 2020 and 2021.

Documentation & Submission• A note or letter prepared by an ophthalmologist, optometrist, primary care

practitioner (PCP), or other healthcare professional indicating that an ophthalmologist or optometrist completed the exam, the date of the procedure, name of procedure and the results.

• Eye exam results read by a system that provides an artificial intelligence (AI) interpretation meet criteria.

• A photograph of retinal abnormalities indicating the date of the funduscopic photography and evidence that an eye care professional reviewed the results. Alternatively, a qualified reading center operating under the direction of a medical director (who is a retinal specialist) may read the results.

• Patient-reported services are acceptable if it is collected as part of the patient's history. It must indicate the date and result and that the test was performed or interpreted by an eye care professional documentation.

• Documentation of a negative retinal or dilated exam (negative for retinopathy) by an Ophthalmologist or Optometrist in the prior year (2020), meets the requirement for this screening.

• Evidence that the member had bilateral eye enucleation or acquired absence of both eyes. Look as far back as possible in the member’s history through December 31, 2021.

• Blindness is not an exclusion

*Optional exclusions are only utilized if a member is not compliant

Codes**: 67028, 67030-31, 67036, 67039-43, 67101, 67105, 67107-08, 67110, 67113, 67121, 67141, 67145,67208, 67210, 67218, 67220-21, 67227-28, 92002, 92004, 92012, 92014, 92018-19, 92134,92201-02, 92230, 92235, 92240, 92250, 92260, 99203-05, 99213-15, 99242-45,

Automated Eye Exam: 92229

CPT II: 2022F, 2023F,2024F, 2025F, 2026F, 2033F, 3072F

Best Practices:• Primary Care Providers (PCP) can

purchase in-office fundus eye cameras (e.g., "Welch Allyn RetinaVue ,“hubble”). The image must be read by an eye care provider (optometrist or ophthalmologist).

• Partner with nearby ophthalmology centers to minimize travel distance for patients.

• Implement a screening template in EMR specifically for diabetics and include the retinal exam; add to patient annual assessment.

• Follow up after a referral to obtain results/consult reports.

• In lieu of a diagnostic report, document the retinal exam was done with dated result and name of the ophthalmic provider.

• Emphasize to patient that diabetes in adults is the leading cause of blindness and it is preventable

Patient Experience:•Patient survey data will contribute to almost half of the Star Rating score in Star Year 2023•Personally connect with your patient prior to discussing the reason for the visit•Review the patient’s medical record prior to the visit and reference it during the appointment•Discuss and validate the importance of the patient’s medications•Schedule future appointments and discuss lab results/upcoming tests

Resources:HEDIS® MY2020/2021 Vol 2 Technical Specs pg 180 - 201

https://www.cdc.gov/diabetes/managing/problems.html#vision

**The codes listed are informational only and are based on HEDIS 2020 technical specifications and do not guarantee reimbursement

Updated 05/2021

Created by CPQ National Education TeamApproved May 27, 2021

https://www.cdc.gov/diabetes/managing/problems.html#vision

Quality quick tips

Statin Therapy for Patients with Diabetes (SPD) 2021Commercial, Medicaid and Medicare

Overview

Diabetes mellitus is a risk factor for cardiovascular diseases (CVDs). Moderate to high intensity statin therapy proves to be beneficial in the primary prevention of CVDs in diabetic patients, ages 40-75. Diabetic patients are 60% more likely to suffer from heart disease than those without diabetes and are 2-4 times more likely to experience a heart disease related death.

Description of Measure

This measure captures the percentage of patients 40-75 years of age during the measurement year 2021 with diabetes who do not have clinical atherosclerotic cardiovascular disease (ASCVD) who met the following criteria. The two rates reported are:

• Received Statin Therapy. Patients who were dispensed at least one statin medication of any intensity during the measurement year.

• Statin Adherence 80%. Patients who remained on a statin medication of any intensity for at least 80% of the treatment period.

NOTE: The treatment period is defined as the earliest prescription dispensing date in 2021 for any statin medication at any intensity through December 31, 2021.

Exclusions

Required:• Patients in hospice or using hospice service anytime during 2021• Patients receiving palliative care anytime during 2021• Myalgia, myositis, myopathy or rhabdomyolysis during 2021• Cirrhosis anytime during 2020 or 2021• Dispensed at least one prescription for clomiphene anytime during

2020 or 2021• End-stage renal disease (ESRD) or dialysis anytime during 2020 or

2021• Female members with a diagnosis of pregnancy anytime during 2020

or 2021• In vitro fertilization anytime during 2020 or 2021• Coronary artery bypass grafting (CABG) during 2020• Myocardial infarction during 2020• Other revascularization procedure during 2020• Percutaneous coronary intervention (PCI) during 2020• Diagnosis of ischemic vascular disease (IVD) during 2020 and

2021

Please see continued exclusions on next page.

Educate Your Patients

• Discuss and document the need

and purpose for statin

medications (lowers LDL and

raises HDL when diet and

exercise alone are not sufficient

to lower cholesterol).

• Talk with patients about any

barriers to medications at each

visit.

• Ask open-ended questions about

concerns related to health

benefits, side effects, and cost.

• Look for untoward side effects of

statins, like myalgias or drug-to-

drug interactions.

• Inform your patient of the

importance of regular visits with

his/her provider

• Review risk factors for heart

disease: smoking, high

cholesterol, high blood pressure,

obesity, family history, not

exercising, poor stress and anger

management, older age.

• Encourage patient to use their

insurance card to obtain diabetes

and statin medications as this

measure is based on pharmacy

claims.

• Encourage patients to use a

pillbox to organize medications

and to set the alarm on their

phone or clock as a reminder to

take medications

• Advise patient to avoid pill-

splitting, medication sharing or

samples of medication as these

do not generate an insurance

claim and will appear non-

compliant.

• Encourage patients to sign up for

refill reminders at their pharmacy,

if available

Resources: HEDIS® MY2020/2021 Technical Specs, Vol 2, pp. 209-2020 Released: 3/31/2021

Cui, JY, Zhou, RR, Han, S, Wang, TS, Wang, LQ, Xie, XH. Statin therapy on glycemic control in type 2 diabetic patients: A network meta‐analysis. J Clin Pharm Ther. 2018; 43: 556–570.

Updated 6/2021

2

Exclusions Cont.

Required:

Note: Supplemental and medical record data may not be used for the following required exclusions:

• Medicare members ages 66 and older as of Dec. 31 of the measurement year who are either:

o Enrolled in an Institutional Special Needs Plan (I-SNP)

o Living long term in an institution

• Members ages 66 and older as of Dec. 31 of the measurement year who had a diagnosis of frailty during

2021 and advanced illness during 2020 or 2021. Advanced illness is indicated by one of the following:

o Two or more outpatient, observation, emergency room, telephone, e-visits, virtual check-ins or

non-acute inpatient encounters or discharge(s)on separate dates of service with a diagnosis of

advanced illness

o One or more acute inpatient encounter(s) with a diagnosis of advanced illness

o One or more acute inpatient discharge(s) with a diagnosis of advanced illness on the discharge

claim

o Dispensed a dementia medication: Donepezil, Donepezil-memantine, galantamine, rivastigmine or

memantine

Optional:

• Members who do not have a diagnosis of diabetes in any setting, during 2020 or 2021 and who had a

diagnosis of polycystic ovarian syndrome, gestational diabetes or steroid-induced diabetes, in any

setting, during 2020 or 2021.

• Organizations that apply optional exclusions must exclude the patients from the denominator for both

rates.

Documentation and Actions

• Prescription fills are captured via pharmacy claims. Only prescription fills processed with a patient’s

health plan ID card can be used to capture a patient’s adherence to their medication.

• Supplemental documentation must include evidence that the medication was dispensed either by a

picture of the prescription bottle or pharmacy receipt or medication administration record. For pharmacy

data, all data elements must be present: the brand/generic name, strength/dose, route and date when the

medication was dispensed to the patient.

• When clinically appropriate, consider writing 90- or 100 -day prescriptions with 3 refills to help improve

adherence and minimize frequent trips to a pharmacy.

• Assess, document and address the barriers for medication compliance with the patient at every office

visit.

• Review the purpose of the patient’s medication and determine if there are any knowledge deficits.

• Prescriptions should have specific instructions. Example of non-specific instructions: Take 1-2 tabs, 2-3

times daily, or take1 tab every 4-6 hours.

• If there is a change in medication dose (medication strength or direction/frequency of dosing), always

send a prescription for the new dose to the pharmacy to discontinue the prescription for the old dose.

• Always check that the directions on your patient’s prescriptions match your instructions. The prescription

needs to represent the accurate dose and frequency of the medication the patient is expected to take.

• Avoid using samples.

• Avoid using manufacturer medication assistance programs.

• When clinically appropriate, prescribe low-cost generic medications to help reduce out-of-pocket costs.

• Reduce complexity of medication regimens. Simplifying medication regimens increases patient

compliance.

• Encourage patients to consider filling their prescriptions through a mail-order pharmacy (if available)

• Clinic staff or pharmacy team members may contact patients to assist in removing barriers to obtaining

medication refills.

• Write a discontinuation order for previous scripts when medications are discontinued or doses are

changed.

Created By CPQ National Education Team

Approved June 09, 2021

Quality quick tips(MAD)

Statin Use in Persons with Diabetes (SUPD) 2021Commercial, Medicaid, Medicare

OverviewDiabetes mellitus is a risk factor for cardiovascular diseases (CVDs). Moderate to high intensity statin therapy proves to be beneficial in the primary prevention of CVDs in diabetic patients, ages 40-75. Diabetic patients are 60% more likely to suffer from heart disease than those without diabetes and are 2-4 times more likely to experience a heart disease related death.

Description of MeasureThe percentage of individuals ages 40–75 with two or more prescription claims, on different dates of service, for any diabetes medication during 2021 who also receive a statin medication during 2021.

ExclusionsExclude patients who have had any of the following diagnosis during 2021:

• Hospice • End Stage Renal Disease • Rhabdomyolysis or Myopathy• Pregnancy • Lactation • Fertility Medication• Liver Disease • Pre-diabetes• Polycystic Ovary Syndrome (PCOS)

Actions• Prescription fills are captured via pharmacy claims. Only prescription fills

processed with a patient’s health plan ID card can be used to capture a patient’s adherence to their medication

• When clinically appropriate, consider writing 90-day prescriptions with 3 refills to help improve adherence and minimize frequent trips to a pharmacy

• Assess, document and address the barriers for medication compliance with the patient at every office visit

• Review the purpose of the patient’s medication and determine if there are any knowledge deficits

• Prescriptions should have specific instructions. Example of non-specificinstructions: Take 1-2 tabs, 2-3 times daily, or take1 tab every 4-6 hours

• If there is a change in medication dose (medication strength or direction/frequency of dosing), always send a prescription for the new dose to the pharmacy to discontinue the prescription for the old dose

• Always check that the directions on your patient’s prescriptions match your instructions. The prescription needs to represent the accurate dose and frequency of the medication the patient is expected to take

• Avoid using samples• Avoid using manufacturer medication assistance programs• When clinically appropriate, prescribe low-cost generic medications to help reduce

out-of-pocket costs• Reduce complexity of medication regimens. Simplifying medication regimens

increases patient compliance• Encourage patients to consider filling their prescriptions through a mail-order

pharmacy (if available)• Clinic staff or pharmacy team members may contact patients to assist in removing

barriers to obtaining medication refills• Write a discontinuation order for previous scripts when medications are

discontinued or doses are changed

Educate Your Patients• Discuss and document the need

and purpose for statin medications (lowers LDL andraises HDL when diet and exercise alone are not sufficient to lower cholesterol).

• Talk with patients about any barriers to medications at each visit.

• Ask open-ended questions about concerns related to health benefits, side effects, and cost.

• Look for untoward side effects of statins, like myalgias or drug-to-drug interactions.

• Inform your patient of the importance of regular visits with his/her provider

• Review risk factors for heart disease: smoking, high cholesterol, high blood pressure, obesity, family history, not exercising, poor stress and anger management, older age.

• Encourage patient to use their insurance card to obtain diabetes and statin medications as this measure is based on pharmacy claims.

• Encourage patients to use a pillbox to organize medications and to set the alarm on their phone or clock as a reminder to take medications

• Advise patient to avoid pill-splitting, medication sharing or samples of medication as these do not generate an insurance claim and will appear non-compliant.

• Encourage patients to sign up for refill reminders at their pharmacy, if available

Resources

Pharmacy Quality Alliance. February 2021. PQA Measure Manual. www.pqaalliance.org

Cui, JY, Zhou, RR, Han, S, Wang, TS, Wang, LQ, Xie, XH. Statin therapy on glycemic control in type 2 diabetic patients: A network meta‐analysis. J Clin Pharm Ther. 2018; 43: 556– 570. https://doi.org/10.1111/jcpt.12690

Updated 03/2021

Updated by CPQ National Education Team 03/30/2021

Approved March 31, 2021

https://doi.org/10.1111/jcpt.12690

Quality quick tips

Breast Cancer Screening (BCS) 2021 Commercial, Medicaid, Medicare

OverviewBreast cancer is responsible for more than 40,000 deaths in the United States each year, along with more than 265,000 cancer diagnoses. Mammograms are the best method to detect early breast cancer. Early detection reduces the risk of dying from breast cancer and can lead to a greater range of treatment options and lower health care costs.

Description of MeasureThe percentage of women 50–74 years of age who had a mammogram any time on or between October 1, 2019 and December 31, 2021 to screen for breast cancer. If one breast has been removed and the other is present, a screening or initial diagnostic mammography is required for the remaining breast.

ExclusionsRequired:Patients who receive hospice or palliative care services anytime during 2021.Note: Supplemental and medical record data may not be used for the following required exclusions:• Patients 66 years of age and older as of December 31, 2021 who meet either

of the following: enrolled in an Institutional SNP (I-SNP) any time during 2021 or living long-term in an institution any time during 2021, as identified by the LTI flag in the CMS Monthly File.

• Patients 66 years of age and older as of December 31, 2021 with frailty and advanced illness.

Optional*: Bilateral mastectomy or unilateral mastectomy with a bilateral modifier during the member’s history through Dec 31, 2021

Actions• Order a screening or initial diagnostic mammogram• Confirm documentation of breast cancer screening in the measurement

period of 27 months• Submit a Mammography Claim• Submit the appropriate ICD-10 diagnosis code if reflecting history of bilateral

or unilateral mastectomy. This code should be submitted annually, preferably as early in the year as possible

Documentation & Submission• Submit a Mammogram report if available in the medical record• If mammogram report is not available, must include year mammogram was

completed. This can be reported by the patient if part of taking a patient’s history by a PCP or specialist who provides primary care related to the condition being assessed. The result is not required.

• Any type or method of mammogram count (screening, diagnostic, film ,digital or digital breast tomosynthesis)

• MRIs, ultrasounds, and/or biopsies do not meet measure criteria.

*Optional exclusions are only utilized if a member is not compliant

Codes**Z90.11 – acquired absence of right breastZ90.12 – acquired absence of left breastZ90.13 – acquired absence of bilateral breastsCPT – Mammography 77061- 77063; 77065 - 77067

Best Practices:• Promote the importance of early

detection with routine screening• Discuss family history and determine if

your patient should start screening at a younger age due to being at a higher risk for cancer

• Discuss patient fears about mammograms

• Inform patient that new technology can find small cancers with less radiation than in the past, allowing for the potential of less health risk

• Send regular reminders to patients when they are due for a screening

Patient Experience:• Patient survey data will contribute to

almost half of the Star Rating score in Star Year 2023

• Personally connect with your patient prior to discussing the reason for the visit

• Review the patient’s medical record prior to the visit and reference it during the appointment

• Discuss and validate the importance of the patient’s medications

• Schedule future appointments and discuss lab results/upcoming tests

Resources:HEDIS® MY2020/2021 Vol 2 Technical Specs pg. 97-102

https://www.mdanderson.org/cancer-types/breast-cancer.html

American Cancer Society: https://www.cancer.org/cancer/breast-cancer/screening-tests-and-early-detection/american-cancer-society-recommendations-for-the-early-detection-of-breast-cancer.html

https://www.cancer.gov/types/breast/mammograms-fact-sheet

**The codes listed are informational only and are based on HEDIS® MY2020/2021 technical specifications and do not guarantee reimbursement.

Updated 05/2021

Created by CPQ National Education TeamApproved May 27, 2021

https://www.mdanderson.org/cancer-types/breast-cancer.html

https://www.cancer.org/cancer/breast-cancer/screening-tests-and-early-detection/american-cancer-society-recommendations-for-the-early-detection-of-breast-cancer.html

https://www.cancer.gov/types/breast/mammograms-fact-sheet

Quality quick tips

Consumer Assessment of Healthcare Providers & Systems (CAHPS): Access to Care

Updated: 4/2021

Why It MattersThe Center for Medicare and Medicaid (CMS) uses this survey to understand a patient’s perception and evaluation of their providers, health care system, and prescription drug services. Due to the importance of patient experience to CMS, the CAHPS survey data collected based on services provided in 2021 are now worth 36% of the overall Medicare Star score, an increase of 10% over the prior year. At 36% of the total score, the CAHPS survey is the single most critical component in Stars calculation.

As a provider, you can ensure patients are more satisfied with the care you provide. Using Familiar Phrases can directly influence your patients’perception of the care they receive. Below are actions you and your office can take to help improve your patient’s perception and experience.

Key Access to Care Survey QuestionsGetting Needed Care (GNC) (weight of 4)

o How easy was it to get care, tests, or treatment you needed? o How easy was it to get appointments with specialists?

Getting Appointments and Care Quickly (GCQ) (weight of 4)o How often were you able to get care as soon as you needed?o How often were you able to get appointments for routine care at a

doctor’s office as soon as you needed?o How often were you able to see the person you came to see within

15 minutes of your appointment time?

Best PracticesAppointments and Scheduling Tips• Communicate timelines for appointments, tests and procedures to manage

expectations. Explain constraints as appropriate.• Offer to schedule the future primary care and specialist appointments,

procedures and tests at the end of every office visit. Try to make it easy for your patients to access care.

• Educate patients on how long it typically takes to schedule various appointments including different types of specialists, etc.

• Inform patients about the availability and how best to use telehealth, urgent care, last minute appointments and other options.

• Give patient options when their provider is unavailable, for example, “Dr. Smith is a great doctor and as you can imagine, this makes him/her popular. His/her current appointments are booking “#” weeks out. Would you like me to set you up to see one of our other excellent doctors and we can give you a call if Dr. Smith has a cancellation before then?”

• Engage patients in the waiting room to minimize perception of wait time: have them complete health screening forms, use health-related posters, TV/video, reading materials, etc., to educate and engage in health education.

Increase Capacity• Leverage NPs and/or PAs to add available appointments. • Establish a time each day for walk-ins and assign dedicated clinical staff.• Extend office hours on weekdays or offer weekend hours.• Reduce wait times to less than 15 minutes from scheduled appointment

times. Inform patients of what to expect with any extended wait times.• Offer telehealth visits and/or provide information on how to access a

telehealth visit, offer to help patient install telehealth app (if applicable).

Familiar Phrases

Using ‘familiar phrases’ encourages patient engagement and timely feedback. These phrases correspond to the CAHPS survey questions and are designed to help patients remember the quality care they receive. Familiar phrases have also been shown to increase patient experience scores.

Consider using these phrases:• We understand the

importance of getting needed care right away

• We want to get you an appointment for a check-up or routine care as soon as you need it.

• We have virtual, or telehealth appointments available to make it easy for you to get care as soon as you need it.

• We want to make it easy for you to schedule routine care/specialty visits. How can I help?

• Thank you for waiting (Mr/Ms Name). We respect your time. Your provider (Name) should be with you shortly. If it is going to be longer, I will stop by myself to check on you and give you an update.

• Is there anything else I can do for you? I have time.

Resources:








Quality quick tips

Consumer Assessment of Healthcare of Providers and Systems (CAHPS): Care Coordination

Updated: 4/2021

Why It Matters The Center for Medicare and Medicaid (CMS) uses this survey to understand a patient’s perception and evaluation of their providers, health care system, and prescription drug services. Due to the importance of patient experience to CMS, the CAHPS survey data collected based on services provided in 2021 are worth 36% of the overall Medicare Star score, an increase of 10% over the prior year. At 36% of the total score, the CAHPS survey is the single most critical component in Stars calculation.

As a provider, you can ensure patients are more satisfied with the care you provide. Using Familiar Phrases can directly influence your patients’perception of the care they receive. Below are actions you and your office can take to help improve your patient’s perception and experience.

Key Care Coordination Survey QuestionsCare Coordination (COC) (weight of 4)Did your personal doctor:

o Have your medical records or other information about your care?o Follow up to give you test results and et the test results as soon as

you needed them?o Talk with you about all the prescription medicines you were taking?o Manage your care among different providers and services?o Seem informed and up-to-date about the care you got from

specialists?

Best Practices Review Medical Records and Be Informed About the Care from Specialists • Proactively get reports or consult notes before time of appointment• Have MA prep chart and request reports not received• Even though the MA often follows-up, it is important that the doctor

references the medical records and specialist notes during discussions with the patient

• Let the patient know that their medical records were reviewed at each visit• Make sure all office and clinical staff use phrases such as “based on your

medical records”, “after reviewing your medical records”, or “your medical records show that…”

• Verbally tell patients that you are reviewing their records and notes from specialists, tests or procedures

• Emphasize care from other providers based on your medical record review (‘I see Dr. Specialist saw you for your condition’).

Managing Care Among Different Providers and Services• Remind patients that you have coordinated with their specialist by using

phrases such as “I received this report from your specialist”Consider saying:

o “We can help you coordinate care between different doctors and facilities. Is there anything we can do to help make connections for you?”

o “Are you getting the help you need to manage your care among these different providers and services?”

o “To provide the best care, I’m just going to take a minute to review your medical record for any new information like tests or prescriptions or visits to a specialist. It’s important to us to manage your care well and make sure you are satisfied”

Familiar Phrases

Using ‘familiar phrases’encourages patient engagementand timely feedback. Thesephrases correspond to the CAHPS survey questions and are designed to help patients remember the quality care they receive. Familiar phrases have also been shown to increase patient experiencescores..

Consider using these phrases:• Let’s discuss the medicines

you are taking• We want to make sure you

get the right care when you need it. Can I help schedule you to see your specialist?

• I want to make sure I’ve explained everything in a way that’s easy to understand. Do you have any other questions?

• I reviewed your medical records and see the results from your recent test, or specialist visit

• Tell me how your appointment with your specialist was for you

Resources:







CAHPS 2021: Care Coordination (cont.)

Test Results • Use a pre-visit checklist for staff to check for lab/test results• Establish a dedicated resource to look for lab/test results daily and to call for results if not received in

expected time frame• Explain recommended tests. Let them know when and how you will share their results. If there are any

delays in getting the results, proactively let your patient know• Always notify patients about their test results, whether positive or negative• If applicable, assign staff to access test results and communicate them to patients• Use a patient portal to automatize the test result communication process and help patient to learn to access

it if needed• When you discuss results, make sure to let the patient know about any follow-up care needed• Ensure the patient has all needed information on where to get tests done• During an in-person or video visit, make sure to look at patient after looking at computer to review test

results or procedures

Prescription Medications• At time of scheduling appointment, remind patients to bring all of their medications in their original bottles to

their appointment so their doctor can review with them• Create or enforce process for MA to review medications when bringing patient into exam room to update

medications. • Even though the MA gathers this information, it is important for the doctor to re-review the medication during

their discussion with the patient at each visit• Discuss medication adherence barriers at each visit and ask open-ended questions about concerns related

to health benefits, side effects, and cost• Consider including reminder for the patient to bring their medications to the visit as part of the reminder call

system• Use the phrase “let’s talk about all of the prescription medicines you are taking” to perform medication

review during routine visits • Always ask about medication changes, but especially after a recent specialist visit or hospitalization.

Strategies for Success• Let patients know that they may receive surveys from Optum and their health plan. Encourage

patients to complete these surveys• Ensure pre-visit preparation is completed. Review labs, referrals, hospital or ED visits, authorizations and

flag them for the provider.• Before the conclusion of visits, offer to schedule appointments for specialists or tests to support

access to care and ease of scheduling for the patient• Save scheduling slots to allow prioritization of urgent, same day appointments when care is needed

right away• New patients usually give low scores when responding to this survey. Make an extra effort to

ensure your new patients feel engaged and supported beginning with their first visit. Let them knowyou have reviewed their past medical history

• Patients with Social Determinants of Health (SDoH) tend to score significantly lower on the CAHPSsurvey. Link these patients to the right resources

• When possible, sit next to the patient when talking to them as this has been shown to increasepatient satisfaction.

• Ask patients how you can better help coordinate care with their other health care providers.• Use interpreter services for patients with language barriers

Created by CPQ National Education Team. Approved 4-27-2021

2021 Primary Care Quality Incentive Program (QIP)

Optum Care Network – Quality Incentive Program (version 2021) 1

2Optum Care Network – Quality Incentive Program (version 2021)

Dear OCN Network Provider,

The Optum Care Network (OCN) of Washington is founded on the belief that we must promote value-based care models for providers and patients. Our goal is to dramatically and sustainably increase access to high quality and affordable medical care for our region. With the Quadruple Aim — a better patient experience, higher quality outcomes, lower cost of care, and an improved experience for providers — we are designing and delivering health care that works better for everyone.

This Quality Incentive Program (QIP) is specifically created to reward primary care providers who give exceptional care, by focusing on population health management, performance in quality measures, and managing chronic health conditions. This program applies to specific products* with OCN in 2021. OCN believes that its primary care providers can meet the goals of the QIP using data, point of care tools and wrap around services to meet objectives. Primary care providers have a unique opportunity to accurately identify their patient’s health conditions, influence overall patient health and to reduce unnecessary medical expenses.

This effort will support the longer-term move to a sustainable health care system and support providers as they transition to value-based models of care delivery. Thank you for partnering with us to provide our patients with comprehensive and affordable 21st century care.

Sincerely,

Julie Stroud MD, MMM, CPE | Optum Care NetworkChief Medical Officer

* Medicare Advantage HMO contracted in 2021, non DSNP, non-Medicaid.

Optum Care Network17930 International Blvd.Suite 1000SeaTac, WA 98188


1. Program description

The QIP is a program structured into four (4) main components:

• Base compensation

• Quality and comprehensive care incentives

• Shared savings opportunity

• Optional Medicare Advantage exclusivity

Foundational to this model is the appropriate identification and management of chronic conditions for the practice’s OCN paneled patient population. By encouraging and incentivizing reporting the health of the population, OCN will create the most accurate picture of patients’ health conditions and therefore the most appropriate risk adjustment of the population. Accurate risk adjustment, matching clinical management of health conditions, and appropriate supporting documentation in chart notes will support the ability to identify opportunities to improve health outcomes of the population. Providers and practices who address quality gaps, ensure accurate risk adjustment, and identify high value care, will be able to share in the savings generated by this holistic approach, while improving the overall patient experience.

Disclaimer: Operational updates may be made periodically, but program design and calculations will remain the same. Any significant changes will be communicated via Practice Alert.


1.1 Base compensation framework

Participating providers in OCN will receive a fee-for-service base rate paid at 100% of the Medicare fee schedule.

1.2 Quality incentive program

Population Health is multi-faceted and requires the comprehensive assessment of each patient’s health needs by accurately identifying the disease burden of the patient and the population, addressing evidence-based quality measures, and addressing total cost of care. To that end, the Quality Incentive Program (QIP) is designed to encourage providers to improve on quality and engage in population health management practices. The QIP consists of several interconnected components:

• Attestations

• Percent conditions addressed

• Select Quality HEDIS/Stars Measures (OCN Composite Star Rating) [HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA)]

• Provider training

2021 OCN PRIMARY CARE INCENTIVE PROGRAM

BASE RATE

100% Medicare Fee Schedule

QUALITY INCENTIVES

Attestations completed$100 PMPQ

% Conditions addressed >90%$8.00 PMPM

Quality4 star $2.00 PMPM

4.5 star $6.50 PMPM

Provider training$125/hr.

SHARED SAVINGS POOLS*

ORANGE POOL GOLD POOL PLATINUM POOL

20% shared savingsNeed 50% pool meeting attendance to stay



GATES TO PARTICIPATE IN SHARED SAVINGS

500 per TIN or 50 per PCP**– and – 4.0 star

1,000 per TIN or 100 per PCP**– and – 4.0 star

2,000 per TIN or 200 per PCP**or 1,000/100 and full exclusivity

– and – 4.5 star

*Any entity with 2,000+ members has its own pool.

OPTIONAL EXCLUSIVITY PMPM

Full exclusivity and acess: $6.50 PMPM^

*Remote access to EMR required for payment to begin, opportunity for retro payment expires every Dec. 31. **Cost to OCN, not the pool.


1.2.1 Attestations

Our goal is to support providers in providing patients with the most comprehensive care, which leads to improved, long-term clinical outcomes, and improved quality of life. To do this, we have established a point of care tool called an attestation for providers to use during a patient encounter to identify and address current chronic conditions and evaluate potential new chronic conditions. Attestations are electronic and/or paper forms that support your practice’s efforts to provide care for patients by listing important chronic conditions and suspected/possible chronic conditions customized to each patient based on prior years claims, pharmacy data, lab data, and clinical chart reviews. Each condition is either listed by the ICD-10 code or by the appropriate Hierarchical Condition Category (HCC). The attestation helps clinicians quickly identify important conditions that need a plan of care by the clinician. Accurate identification of conditions for each patient, together with supporting clinical documentation in provider chart notes, ensures applicable resources are available and appropriately allocated to manage the needs of the patient throughout the year. Each condition listed on an attestation should be evaluated by a licensed provider at least once during each calendar year. A face-to-face visit between the patient and the provider with appropriate documentation of the conditions addressed is required when using the attestation. CMS, during the Public Health Emergency, accepts documentation and care delivered via telemedicine visits with audio visual connections to be an acceptable means to address these chronic conditions. Phone encounters alone continue to be insufficient.

Some providers have chosen to integrate the information contained in these attestations into their EMR. We can help support incorporation of these conditions into EMR systems, as well as providing support to submit these forms in a digital format.

These forms are pre-populated for each patient assigned to your practice. For each condition, providers are asked to evaluate the listed condition in a face-to-face visit, document the plan of action for care in their progress notes, and either “agree” or “disagree” with each condition on the form.

• Agree indicates the diagnosis was reviewed and assessed. The provider is attesting that the diagnosis is valid, and the provider has addressed the condition during the visit on the given date of service with chart notes stating an assessment and plan of each agreed to diagnosis.

• Disagree indicates the diagnosis was reviewed and is currently not present.

• Conditions should be evaluated and documented at the highest level of specificity for the member, and the most accurate ICD-10 code should be reported on the claim for that date of service.

• “Disagree” conditions indicate that the member does not have the condition upon evaluation and should not be documented on the progress note or a claim/encounter.

• Attestations are considered approved when all the following requirements are satisfied:

– All conditions are addressed, either agree or disagree

– All agreed conditions have been documented in the progress note

– The encounter progress notes are included with the submitted attestation

– The encounter is a face-to-face visit between the patient and licensed practitioner

– The date of service, print date, and submission date are within the allowed guidelines of the attestation period

– The provider’s signature, date, legible printed full name and credentials are present on the form


Attestation forms can be submitted electronically or via fax to the fax number listed at the bottom of the form with the supporting progress note. To qualify for payment, attestations must be submitted to Optum Care Network within thirty (30) days of the date of service (DOS), and the print date on the form is within 30 days of the date of service.

Eligible payment for each completed attestation will be reimbursed at $100. In order to qualify for additional payments per quarter following the first completed attestation, there must be additional diagnoses and/or HCC codes presenting on the attestation for that member and there must be another unique DOS for a face-to-face visit where that attestation was completed. The maximum amount paid is up to $400 per calendar year, per patient with no more than one payment per quarter.

1.2.2 Percent conditions addressed

Addressing chronic conditions and potential suspected conditions at least once per calendar year for each patient is critical to support the accurate health status of each patient. By addressing conditions that are presented on attestations, providers can help manage conditions that may impact patients’ health status.

Percent conditions addressed is defined by addressing all available conditions (HCC and ICD-10 codes) for the practice’s paneled patient population. Conditions are considered addressed when providers “agree” with presented conditions and provide supporting documentation in the form of a progress note, or when providers “disagree.” Addressed conditions are captured via submitted and approved attestations. This requires each listed condition to either be “agreed to” or “disagreed to” on the attestation form. Each “agreed to” condition (ICD-10) must be submitted via a billable claim or encounter as required by CMS, with supporting documentation in the clinical chart note.

Percent conditions addressed payment will be based on the prior year’s performance (visit dates Jan. 1–Dec. 31) with OCN paneled patients and will be paid to the practice during the payment year (the year following the performance year). Practice performance calculations will be finalized during Q1 of the payment year.

For practices that address at least 90% of all available conditions presented on the attestation forms for the OCN paneled patients, an incentive of $8.00 per-member-per-month (PMPM) will be paid to the practice.

Percent conditions addressed measurement: The denominator is the count of all possible risk adjusted ICD-10 codes or HCCs from all sources (includes agreed, disagreed, and pending). The numerator is the amount of codes addressed (including agreed and disagreed). The provider receives credit for both agreed and disagreed statements.

Access to medical records needs to be given to validate any submitted conditions addressed. Clinics with more than 30 paneled patients across all Medicare Advantage plans in which practice is participating with OCN (see Optum Care Network Group Practice Agreement) are eligible for this component of the QIP program.


1.2.3 Quality

OCN is committed to clinical excellence, superior outcomes, and patient-centered care. Using national best practices and benchmark data, we hold our network partners to a high standard. Our role is to support them in reaching their quality goals and delivering on that commitment. A key component to our quality program is to measure and provide feedback on the performance of the practices and the network.

Quality performance is the practice’s attainment of a composite score of select CMS Medicare Advantage performance measures. Performance on these measures will be converted by OCN to a practice-specific star rating. To determine the OCN composite star rating, individual measures are weighted and aggregated using a scale of 1 to 5 stars. Requirements and benchmarks for each measure are determined by CMS. The selection of measures in the quality composite stars set are reviewed and approved by the OCN quality committee annually. The quality committee draws its membership from practicing clinicians across the OCN and support teammates with expertise in quality improvement and practice transformation.

Quality payment will be based on the prior year’s performance (visit dates Jan. 1–Dec. 31) with OCN paneled patients and will be paid to the practice during the payment year (the year following the performance year). Practice performance calculations will be finalized during Q1 of the payment year.

There are two (2) incentive tiers:

• $2.00 PMPM for a composite star rating of 4.0–4.49

• $6.50 PMPM for a composite star rating of 4.5+

Measurement period example: The star rating for each provider for 2021 performance will be calculated based on data received through February 28, 2022 for 2021 dates of service. This incentive is then paid monthly in 2022.

Clinics with more than 30 paneled patients as defined in 1.2.2 are eligible for this component of the QIP program.

1.2.4 Provider training

Provider training supports individual or group training on key topics that support practice performance on the QIP. Core topics include risk adjustment coding and population health management. Reimbursement for provider training is $125/hour. Some select trainings may include $25/hour for support staff when attending with a provider in order to support appropriate workflow optimization and knowledge of population health approaches to care.


1.3 Shared savings pools

Shared savings is a program for qualifying practices and providers to participate in an upside financial arrangement that supports population health management. This program applies to patients covered by MA plans as listed in your Optum Care Network Primary Care Group Practice Agreement.

Practices that are high performers (4+ stars) will be eligible to share in savings on a quarterly and annual basis. Savings will be determined by subtracting total health care expenses and operating costs from revenue.

1.3.1 Shared savings pool participation requirements

OCN will assign qualifying providers to appropriate pools based on geography and pool designations below. Shared savings pool are based on the tiers and gates defined below:

SHARED SAVINGS POOLS*

ORANGE POOL GOLD POOL PLATINUM POOL




GATES TO PARTICIPATE IN SHARED SAVINGS

500 per TIN or 50 per PCP**– and – 4.0 star

1,000 per TIN or 100 per PCP**– and – 4.0 star

2,000 per TIN or 200 per PCP**or 1,000/100 and full exclusivity

– and – 4.5 star

*Any entity with 2,000+ members has its own pool. **Cost to OCN, not the pool.

The membership threshold requirement for pool participation is based on eligible members during the second contract effective month with OCN.

The practice may only enter shared savings pool on January 1st or July 1st (whichever comes first after their OCN contract effective date).

Practices with a total membership of 2,000 or more members, across all eligible payors/products for which the practice participates, will be eligible for their own shared savings pool.

The OCN composite star rating threshold requirement for pool participation is based on the prior year of performance of the practice as reported by OCN or derived from health plan reported data.

The practice must have an OCN contract that is in effect at the time of the final shared savings calculation and date of disbursement or will forfeit all shared savings.

To remain in a shared savings pool, practices must participate in regularly scheduled meetings with pool partners and OCN medical directors. Meetings will be structured to support the performance of the pool and to ensure best practices are shared among pool participants. Pool meeting participants must include at least one provider from each practice location.


1.3.2 Shared savings pool calculation and example

OCN will assign qualifying providers to appropriate pools based on geography and pool designations below. Shared savings pool are based on the tiers and gates defined below:

REVENUE

EXPENSE

SHARED SAVINGS

POOL

• Applicable claims expense (e.g. institutional claims, professional claims, ancillary claims, IBNR factor – Incurred But Not Reported)

• Quality Incentive Payments (QIP)• Administrative fee to OCN (8% of revenue)

• Shared savings % x surplus = total $ to pool• Total remaining $ then divided by membership in pool to get a PMPM• PMPM multiplied by TIN membership and paid out

• Based on actual membership in the pool• Revenue compose of CMS rates and Risk Adjustment Factor (RAF)

The example pool calculation below is for illustration purposes only. Actual amounts will be different. The layout is subject to change, but the overall content and calculations will remain the same.

1.3.3 Shared savings pool payment


ILLUSTRATION

Pool ABC – Optum Care Network of Washington

Shared savings calculation Gross PMPM Formula (Gross)

Membership 12,000 1,000 A

RAF score 1.00

Capitated paid revenues $10,200,000 $850.00 B

Expensese

FFS medical * $6,720,000 $560.00 C = Sum (1–6)

Acute IP $2,400,000 $200.00 1

OP facility $1,440,000 $120.00 2

Other facility (SNF, LTAC, etc.) $300,000 $25.00 3

PCP office/ IP/OP $900,000 $75.00 4

Specialist office/IP/OP $1,440,000 $120.00 5

Ancillary services (lab, X-ray, PT, wound care) $240,000 $20.00 6

Capitated medical $987,000 $82.25 D

Other medical services $60,000 $5.00 E

Stop loss provision $93,000 $7.75 F

Total pool QIP (Attest., Quality, % Cond Addressed, Training) $325,000 $27.08 G

Total medical expense $8,185,000 $682.08 H = C + D + E +F+G

Less administrative fee 8% $816,000 $68.00 J = B x 8%

Gross margin surplus/deficit $1,199,000 $99.92 K = B - H - J

Net remaining pool funding (assumes gold pool) 30% $359,700 $29.98 L = K x 30%

Medical costs ratio % 80.25 % M = H / B

* FFS medical expenses include Incurred But Not Reported (IBNR) factors.


The disbursement of shared savings to each eligible practice will be based on their portion of the pool membership as included in the shared savings calculation.

Payment will occur quarterly and will be no later than 120 days after the end of each quarter. Fifty percent (50%) of shared savings will be paid quarterly and 50% will be held for the annual reconciliation. The annual reconciliation will occur no later than 180 days after the end of the calendar year. Previous quarterly shared savings payments to the practice will be netted against the next quarter and final shared savings amounts. The practices in each pool will receive shared savings payments in sum no greater than their pool’s net remaining pool funding amount.

Practices will have 30 days from the receipt of the final reconciliations to audit the reconciliations and submit any revisions to OCN. OCN shall provide such additional information as practices may reasonably request to permit such audit. If group fails to submit any proposed revisions to OCN WA within thirty (30) days of being provided additional information, the final reconciliation shall be deemed final.

OCN shall have thirty (30) days from the receipt of the group’s proposed revisions to review such revisions, make any necessary adjustments to the final reconciliation, and return the revised final reconciliations to group. Such revised final reconciliations shall be at the sole discretion of OCN.

1.4 Optional exclusivity and access

Participating practices will receive a $6.50 PMPM if they agree to exclusivity and access with OCN. Confirmed remote access to the practices EMR is required for funds to be paid. A minimum of four logins to accommodate quality and risk adjustment data abstraction. Funds expire December 31st if remote access is not confirmed by OCN.

Check with your practice advocate for details.


Notes

optum.com

Optum is a registered trademark of Optum, Inc. in the U.S. and other jurisdictions. All other trademarks are the property of their respective owners. Because we are continuously improving our products and services, Optum reserves the right to change specifications without prior notice. Optum is an equal opportunity employer.

© 2021 Optum, Inc. All rights reserved. 4137072 02/21

Optum® is a registered trademark of Optum, Inc. in the U.S. and other jurisdictions. All other brand or product names are trademarks or registered marks of the property of their respective owners. Optum is an equal opportunity employer.

Background & Synopsis Optum Outreach is a program created to better connect with our patients. Optum staff reach out to patients and offer a concierge scheduling service. The program helps engage patients in their healthcare and encourages patients to schedule and complete their Annual Wellness Visit (AWV), HCC Care Gap visit, or to establish care with a Primary Care Provider. The first Optum Outreach campaign of 2021 focuses on the patient population of whom have not yet established care within the organization. Optum Outreach will target patients who have not had a medical visit within the past three years, or an otherwise “unengaged” patient, as identified by Optum Care Network (OCN) and the practice.

Who reaches out to the patients? • Optum outreach team members, a group of 6

centrally located staff. Their first names are: Asia, Nenita, Tina, Yihong, Aaliyah, and Susan.

• Optum Outreach will show on Caller ID as either: o Practice Name o United Health Care o Optum Care Network

Depending on patient’s phone carrier

Incentive • $25 gift card sent from Optum Bank 6 weeks after

AWV completed. • Optum Bank Contact number: (877) 370-5329

Which patients are contacted?

• Medicare Advantage members with the following health plans: Humana MA, Premera MA, UHC MA, UHC Dual (MA and Medicaid eligible - DSNP)

• Non-contracted UHC MA & UHC Dual.

Improving communications:

• Each morning, the Optum Outreach team will call the practice first, prior to making the patient outreach calls.

• Each Patient will be contacted (or attempted contact) a maximum of three times by this team.

o Reports will be provided after completion of each call attempt. The report will include details and action items for the Practice, if applicable.

When Do the Campaigns Begin? • Feb 22, 2021: Unengaged and PCP change • Mar 2021: AWV Outreach • Oct 2021: Open Chronic Conditions and

End of Year push

Strategies for a successful campaign:

• Clinics to follow up with patients of whom requested a return call to schedule the AWV or Open Chronic Conditions visit.

• Note: Medicare Advantage and United Dual Eligible (DSNP) patients do not need to wait 365 days from their last AWV. They are entitled to one AWV per calendar year.

• Clinics to ensure that scheduling team members are familiar with the campaign, as patients may reach out to the practice directly, in response to the Optum Outreach team’s initial phone call/message left.

• Note: Unengaged patients, or patients that have not been established with a provider, may not be in your EMR system. The unengaged patient will need the practice to establish a care visit with a PCP for the member.

• Coordinating care

Transportation Resources • UHC MA/UHC Dual patients have benefit of:

48 one-way* or 24 round trips per year, to use for transportation to healthcare providers or pharmacies. For reservations call 866-418-9812, Mon – Fri 8:00 am – 5:00 pm. Min notice: 3-days, Max notice: 2-weeks. *Distance not to exceed 50 miles one way.

• Humana MA patients have benefit of: 12 one-way trips to plan approved locations not to exceed 25 miles per trip. For reservations call 866-588-5122, Mon – Fri 8:00 am-5:00 pm. Min notice: 3-days, Max notice: 2-weeks. Patient will need to provide health plan name, member ID, name and address of medical provider, appointment day and time, pick up time and location.

• Note: Transportation benefits are available all year at no cost to the practice or provider.

Optum® is a registered trademark of Optum, Inc. in the U.S. and other jurisdictions. All other brand or product names are trademarks or registered marks of the property

of their respective owners. Optum is an equal opportunity employer. *HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

Background

HouseCalls is a program available to qualified members of Optum Care Network. It offers a yearly in-home visit completed by an Advanced Practice Clinician. HouseCalls helps improve performance on 26 key Star/HEDIS measures and aids the patient to follow treatment plans and identifies potential care opportunities. There is no charge to the provider nor the patient. This visit does not replace the pr oviders ability to conduct an Annual Wellness Visit; the patient is encouraged to see their PCP and follow their care plan.

Which patients are contacted?

• Delegated Medicare Advantage (Humana MA, Premera MA, UHC MA, UHC Dual).

• Non-contracted UHC MA & UHC Dual.

Communication to patient:

• Mailer o HouseCalls will send a letter to patient

describing the program.

• Live Call o HouseCalls will reach out to the patient and

schedule an Assessment via telehealth or as an in-home visit, depending on patient preference and following current COVID safety guidelines.

• Reminder Call o Each patient will receive a confirmation call

from the Advanced Practice Clinician (APC) the day before the visit.

Appointment Components:

• During the visit the Practitioner will: o Review the patient’s

health history (Past & Active) o Conduct a physical examination (including

health screenings, urinalysis, and labs/tests as appropriate)

o Complete a medication reconciliation o Provide tailored education & referrals

• After the visit o Referrals are generated (as needed)

o Visit summary is mailed to patient and PCP of record.

o Patient will receive a prepaid Mastercard for participating in the program.

Members can call directly for their in-

home, telehealth, and/or tablet

delivery services:

• OCN UHN MA members: (877) 605-5253 • OCN Humana & Premera MA members:

(877) 497-1458

Incentive

• $15 gift card sent from HouseCalls 6wks. after

service is completed.

• Prepaid Rewards Care Number: (833) 634-3155

98% Member Satisfaction Rate for

HouseCalls Program

Details of the Appointment:

• Focus of HouseCalls is to help encourage the

patient to schedule regular appointments with

their PCP and to capture chronic conditions,

following their PCP’s care plan.

Note: The in-home assessment does not

replace the AWV.

• OCN has provided HouseCalls with the

following files to better understand the

patient need and medical history:

o Patient Roster, Open Care Gaps,

Medical Claims, Suspect Data, Lab

Claims, MMR Data, Pharmacy Claims,

and RAPS Data

Connecting the care continuum:

• HouseCalls can connect the member to

additional care team resources to manage

their health status and ongoing care needs.

o Resources: Pharmacist, RN Care

manager, Social worker, Clinician

support, Behavioral Health,

Case/Disease management, and

Pharmacy benefits manager (PBM)

When Does the Program Begin?

• Week of Feb 22, 2021: NPN Legacy &

Non-contracted UHC Duals

• Mar 2021: NPN Legacy (UHC, Humana,

Premera) & Non-contracted UHC MA

• Programs runs through the end of 2021

Optum® is a registered trademark of Optum, Inc. in the U.S. and other jurisdictions. All other brand or product names are trademarks or registered marks of the property

of their respective owners. Optum is an equal opportunity employer. *HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

Background

This program’s goal is to convert delegated Medicare Advantage patients eligible for the incentive to be seen by end of year. The impact of the incentive is to encourage members to schedule and complete a telehealth or in-person Annual Wellness Visit (AWV) once per calendar year or participate in a wrap-around service such as an in-home assessment.

Who Qualifies?

• Optum Care Network (OCN) delegated Medicare Advantage members (Humana MA HMO & DSNP, Premera MA HMO, UHC MA HMO & Dual/DSNP)

How to Qualify?

• An Annual Wellness Visit (G0438, G0439, G0402, 99385-99387, 99395-99397) completed with an in-network provider.

• Once the claim has been sent and accepted, a monthly file is sent to Optum Bank for processing. It takes approximately 60-days from the date of visit to receive their wellness gift card.

• This program will run through the end of 2021 with an opportunity to offer another incentive in 2022.

Incentive Information:

A member has questions: What do I do?

• HouseCalls processes their own incentives; prepaid rewards care number is (833) 634-3155. • Optum Bank activation number is (833) 573-8144, and customer service number is (877) 370-5329.

• Check if the member has active coverage of one of our delegated plans (above). • Checking billing: Has an AWV code been submitted, and claim processed?

• Check timing: Has it been 60-days from the visit date? • If additional information regarding a patient incentive status is needed, please contact your Practice

Advocate.

Optum® is a registered trademark of Optum, Inc. in the U.S. and other jurisdictions. All other brand or product names are trademarks or registered marks o f the property of their respective owners. Optum is an equal opportunity employer.

Medical Management

• Optum Care Network medical management programs provide high touch care coordination within hospitals, skilled nursing facilities (SNFs), and patients’ homes. These programs work in collaboration with the patient, the family/support system, providers, and key stakeholders to coordinate discharge, healthcare services, community resources and referrals to the appropriate next level of care.

Medical Management Services

• Patients may be enrolled into medical management programs through several pathways. Optum Care Network utilizes risk stratification algorithms to identify patients and may invite patients to enroll post -acute stay or after diagnoses of certain conditions. Providers may also request medical management services for their patients. Optum Care Network will coordinate closely with providers for any patients enrolled into medical management programs.

Case Management

o Dedicated nurse case manager

o Telephonic and In-person support

o Health goal development

o Disease management education and medication review

o Post-discharge follow-up

o Licensed social workers can assist patients with financial resources, housing, transportation, placement, and meal assistance

Transition to Home Visits

o Short-term case management follow-up post-discharge

o Collaboration with health care providers

o Support safe discharge until patient can return to seeing PCP

o Coordination of transitional services and supports

Medical Management Request Process

To refer patients to Optum Care Network medical management programs, call 1-253-627-4113 or

complete a referral form and fax to 1-253-627-4708.

optum care network provider binder

Documents