PROVI D ER N EWSLETTERUniCare Health Plan of West Virginia, Inc.

www.unicare.com

October 2018

Table of Contents

Substance use disorders in pregnancy and neonatal abstinence syndrome programs available for members

Page 2

Vaginal birth after cesarean shared decision-making aid available Page 3

Cervical length measurement by transvaginal ultrasound Page 3

EDI Gateway migration Page 4What Matters Most: Improving the Patient Experience CME Page 4

Electronic claim payment reconsideration Page 5Diabetes Health Home pilot program Page 6New diabetes program Page 7Credentialing and recredentialing Page 8Member rights and responsibilities Page 9New Case Management programs now available Page 9

Behavioral health notifications: important psychological testing update Page 10

Coding spotlight: substance use disorders and smoking Page 11

HEDIS coding guidelines for well-child visits Page 11Medical Policies and Clinical Utilization Management Guidelines update Page 12

Prior authorization requirements Page 13

October 2018UWV-NL-0153-18(Revised October 1, 2018)

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Substance use disorders in pregnancy and neonatal abstinence syndrome programs available for membersSubstance use disorders are on the rise and are of particular concern in women of child-bearing age who are or may become pregnant.

Women are at risk for delivering babies who are born preterm, low birth weight and with neonatal abstinence syndrome (NAS)/neonatal opioid withdrawal syndrome (NOWS) if they:• Take prescribed opioids for pain or addiction treatment.• Misuse prescribed opioid medications.• Use opioids illicitly.• Use opioids in combination with benzodiazepines, selective serotonin reuptake inhibitors (SSRIs) or

tobacco.

UniCare Health Plan of West Virginia, Inc. (UniCare) NAS programIn response to the opioid epidemic, UniCare developed a comprehensive NAS program that seeks to improve outcomes for women and newborns affected by substance abuse disorders, including opioid use and misuse before and during pregnancy. The program includes primary and secondary interventions including efforts to prioritize pregnant women for screening, increase member engagement in treatment and recovery, increase access to reproductive counseling and preconception care, and increase familiarity of evidence-based standards of care for newborns with NAS.UWV-NL-0128-18

For inormation on how you can

support your patients, view the full

Provider Bulletin.

Page 3 of 13

Vaginal birth after cesarean shared decision-making aid availableAs part of our commitment to provide you with the latest clinical information and improve member outcomes, we have posted a vaginal birth after cesarean (VBAC) shared decision-making aid to our provider site. This tool has been reviewed and certified by the Washington Health Care Authority* and is available to aid in discussions with your patients regarding their treatment options.

* The Washington Health Care Authority is recognized as a certifying body by NCQA.UWV-NL-0135-18

Cervical length measurement by transvaginal ultrasoundIn our efforts to improve pregnancy outcomes, including the prevention of preterm birth, UniCare Health Plan of West Virginia, Inc. previously communicated our endorsement of the American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal Fetal Medicine (SMFM) guidelines on cervical length (CL) screening and progesterone treatment.

We continue to encourage you to obtain a CL measurement with your patient’s routine prenatal anatomic evaluation ultrasound. For claims submitted on or after January 1, 2019, if a vaginal approach is necessary in addition to an abdominal scan to obtain this measurement, the transvaginal ultrasound will be considered for a multiple procedure reduction.

When a routine anatomic evaluation ultrasound (76801, 76802, 76805, 76810) and a transvaginal ultrasound (76817) are billed on the same day by the same provider, the transvaginal ultrasound is considered a part of the multiple procedure payment reduction policy and will be paid at 50% of the applicable fee schedule, and the complete procedure will be paid at the full applicable fee schedule.UWVPEC-0833-18

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EDI Gateway migrationUniCare Health Plan of West Virginia, Inc. has partnered with Availity to become our designated EDI Gateway, effective January 1, 2019.

What does this mean to you as a provider?All EDI submissions currently received are now available on Availity. Please note, there is no impact to provider participation statuses and no impact on how claims adjudicate.

Next stepsContact your clearinghouse to validate their transition dates to Availity. If your clearinghouse notifies you of changes regarding connectivity, workflow or the financial cost of EDI transactions, there is a no-cost option available to you — You can submit claims directly through Availity!

Register with AvailityIf you wish to submit directly through Availity for your 837 (claim), 835 (electronic remittance advice) and 27X (claim status and eligibility) transactions, please visit https://www.availity.com to register.

We look forward to delivering a smooth transition to the Availity EDI Gateway. If you have any questions please contact Availity Client Services at 1-800-282-4548, Monday to Friday, 8 a.m. to 7:30 p.m. Eastern time. UWV-NL-0149-18

What Matters Most: Improving the Patient Experience CMEAre you looking for innovative ways to improve your patients’ experiences?Numerous studies have shown that a patient’s primary health care experience and, to some extent their health care outcomes, are largely dependent upon health care provider and patient interactions. Recently, UniCare Health Plan of West Virginia, Inc. (UniCare) announced the launch of a new online learning course — What Matters Most: Improving the Patient Experience — to address gaps in and offer approaches to communication with patients. This curriculum is available at no cost to providers and their clinical staff nationwide.

For more information on What Matters Most: Improving the Patient Experience, check out the full Provider Update on our website.UWV-NL-0151-18

Page 5 of 13

Electronic claim payment reconsiderationCurrently, providers can submit claim payment reconsiderations verbally, in writing or electronically. We are reaching out to notify you about some exciting new tools for electronic submission that will become available through the Availity Portal. You should soon see changes in the provider manual that will outline this new information regarding claim remediation tools through the Availity Portal.

Beginning December 6, 2018, providers will have the ability to submit claim reconsideration requests through the Availity Portal with more robust functionality. For you, this means an enhanced experience when: • Filing a claim payment reconsideration. • Sending supporting documentation. • Checking the status of your claim payment reconsideration. • Viewing your claim payment reconsideration history.

New Availity Portal functionality will include: • Acknowledgement of submission at the time of submission. • Notification when a reconsideration has been finalized by UniCare Health Plan of West Virginia, Inc. • A worklist of open submissions to check a reconsideration status.

With the new electronic functionality, when a claim payment reconsideration is submitted through the Availity Portal, we will investigate the request and communicate an outcome through the Availity Portal. Once an outcome has been determined, the Availity Portal user who submitted the claims payment reconsideration will receive notification informing him/her that the reconsideration review has been completed. If you are not satisfied with the reconsideration outcome, continue to follow the existing process to file an appeal, as outlined in your provider manual.

Look for announcements on the Availity Portal for upcoming training opportunities. Providers who have questions as they begin to use the new functionality should contact our Customer Care Center at 1-800-782-0095.UWV-NL-0148-18

Page 6 of 13

Diabetes Health Home pilot programThe Diabetes Health Home started in April 2017 as a pilot program designed for eligible Medicaid members with pre-diabetes, diabetes or obesity and at risk of having anxiety or depression. West Virginia’s Health Homes Program is designed to meet member needs so they get quality care. Members’ medical care can be managed with other services to keep them healthy.

This pilot program is in 14 counties:• Boone• Cabell• Fayette

• Kanawha• Lincoln• Logan

• Mason • McDowell• Mercer

• Mingo• Putnam• Raleigh

• Wayne• Wyoming

In order to become a Health Home provider you must submit a Health Home Provider Application and narrative. The application can be found by visiting https://dhhr.wv.gov/bms/WV%20Health%20Homes/DHH/Pages/default.aspx and selecting Provider Information.

The narrative asks providers to address the following: • Describe your practice and your practice relationships with other health care providers in your area and why

your practice is suited to be a Health Home provider.• Describe your ability to capture member information and coordinate care for the Health Home population.• Describe your ability to report the quality measures as outlined in the State Plan Amendment.

If you have any question in regards to the Health Home initiative or would like technical assistance, please contact KEPRO at 304-343-9663.

Please return your application and narrative to:The Bureau for Medical Services Attn: Richard Ernest Jr.350 Capitol Street, Room 251Charleston, WV 25301UWV-NL-0146-18

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New diabetes programUniCare Health Plan of West Virginia, Inc. is now licensed to educate members and train educators in a new diabetes self-managed education (DSME) program called DEEP (Diabetes Education Empowerment Program). DEEP is a program developed by the Midwest Latino Health Research, Training and Policy Center at the University of Illinois at Chicago. The goals are to reduce diabetes care disparities among minorities in the United States and to prevent and/or reduce adverse health outcomes related to diabetes through incorporating adult education, empowerment principles and participatory techniques. It facilitates changes in knowledge, behavioral and clinical indicators.

If you would like to know more about this program, please call Customer Care at 1-800-782-0095.UWV-NL-0145-18

Objectives: Program overview:

• Reduce diabetes risk factors, including obesity and hypertension

• Increase knowledge of diabetes and its risk factors

• Increase self-management skills• Manage psychosocial issues• Facilitate short- and long-term

behavioral change

• Format includes training-of-trainers and an educational curriculum

o Training-of-trainers targets community health workers o Educational curriculum engages community residents

in self-management practices for prevention and control of diabetes

• Taught in four countries, and 38 states within the United States

Page 8 of 13

Credentialing and recredentialingCredentialing updates You must inform CAQH and UniCare Health Plan of West Virginia, Inc. (UniCare) of changes to your practice. UniCare members rely on the accuracy of the information in our online UniCare Provider Finder®. CAQH will send automatic reminders for you to review and attest to the accuracy of your data every four months. If you are a participating provider, you may submit most changes online by using the Change Your Information form available at https://proview.caqh.org/pr.

Recredentialing When you are scheduled for recredentialing, UniCare will determine if you have completed the ProView credentialing process and have authorized UniCare to access your information or if you have selected global authorization. If you have made this authorization, UniCare obtains your current information from the ProView database and completes the recredentialing process without contacting you.

If your recredentialing application is not available to UniCare through CAQH for any reason, UniCare will fax you a reminder to update the application.

Please note: You must enter your changes into the ProView database and grant access to UniCare during the credentialing and recredentialing process. Only health care plans participating in the ProView database and those to which you have granted access receive these changes.

Customer Care Center phone: 1-800-782-0095 Customer Care Center fax: 1-888-438-5209 Hours of operation: Monday to Friday, 8 a.m. to 6 p.m.

If you have any questions about accessing the ProView database, contact the CAQH Help Desk: 1-888-599-1771. Operating hours: Monday to Thursday, 7 a.m. to 9 p.m.; Friday, 7 a.m. to 7 p.m. Email: providerhelp@proview.caqh.org.UWV-NL-0142-18

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Member rights and responsibilitiesThe delivery of quality health care requires cooperation between patients, their providers and UniCare Health Plan of West Virginia, Inc. One of the first steps is for patients and providers to understand their rights and responsibilities. Therefore, in line with our commitment to involve participating providers and members in our system, UniCare has adopted a member rights and responsibilities statement. This statement can be found on our website (www.unicare.com > Providers > State Sponsored Plan providers > West Virginia - Medicaid Managed Care > Provider Manual and Important Updates > Provider Manual and reference the Member Rights and Responsibilities chapter).

If you’d like us to mail you a copy, call our Customer Care Center at 1-800-782-0095. Our Customer Care Center representatives serve as advocates for our members.UWV-NL-0143-18

New Case Management programs now availableThe UniCare Health Plan of West Virginia, Inc. (UniCare) Case Management program, provided at no cost to our members, offers expert assistance in the coordination of complex health care. The Case Management department includes experienced registered nurses and licensed clinical social workers who address our members’ medical needs as well as psychological, social and financial issues. In addition to traditional case management programs, UniCare has added programs to address:• Children with special health care needs.• Neonatal Abstinence Syndrome reduction• High-risk OB members.• NICU.• High-Intensity Integrated Team (HIIT) program:

a program for members with high intensity in behavioral health and physical health diagnosis whom are hard to reach and/or hard to engage.

• High A1C/Diabetes program.• Postdischarge management.

To request case management services, providers, nurses, social workers and members or their representatives may call 1-304-347-2475 or send a Case Management Referral Form by email to wvcmreferrals@anthem.com. A case manager will respond to a request within three business days. You can find the form by visiting www.unicare.com > Providers > State Sponsored Plan providers > West Virginia - Medicaid Managed Care > Forms Library > Case Management Referral Form.UWV-NL-0144-18

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Behavioral health notifications: important psychological testing update

UniCare Health Plan of West Virginia, Inc. (UniCare) appreciates the compassion with which you care for your patients, our members. We know the provision of high-quality mental health care services for UniCare members requires successful collaboration. Because timely decisions and successful approvals of medically necessary services are an important part of collaboration, we encourage you to review the medical necessity criteria available in the following Clinical Utilization Management Guidelines:• Screening and Testing for Autism Spectrum

Disorders and Rett Syndrome• Neuropsychological Testing• Psychological Testing

Effective October 1, 2018, we will review all requests using these guidelines. You can help streamline the authorization process to ensure timely claims processing by including the appropriate documentation to demonstrate that all criteria are met. UWV-NL-0134-18

Where can I find Medical Policies?The Medical Policies can be found on the Provider Resources page of our website: 1. Go to www.unicare.com.2. On the top menu bar, under OTHER

UNICARE WEBSITES, select Providers.3. Under Resources for:, select State

Sponsored Plan providers on the left side of the page.

4. Choose West Virginia – Medicaid Managed Care.

5. You are now on the Provider Resources page. On the left side of the page, find Medical Policy and Clinical UM Guidelines and select Enter.

6. Scroll to the bottom and select Behavioral Health Clinical UM Guidelines.

7. Follow instructions on this page to find a particular guideline or policy.

Page 11 of 13

Coding spotlight: substance use disorders and smokingSubstance use disorders can affect a person’s brain and in turn their behavior. Substance use can start with the experimental use of a drug in a social situation or exposure to prescribed medications. Eventually it can lead to an inability to control the use of the legal or illegal drug or medication. When a patient is diagnosed with an alcohol- or drug- use disorder, the diagnosis is often more complex, as such conditions are susceptible to both psychological and physiological signs, symptoms, manifestations and comorbidities. This article will provide you with the information you need to provide high-quality care to patients struggling with substance use as well as how to code for the services provided to them.

For detailed information on substance use disorders and smoking including health risks, diagnosis and treatment, HEDIS® quality measures related to substance use, and coding information, please view the full update on our provider website.UWV-NL-0141-18

HEDIS coding guidelines for well-child visitsIt is important to code your services correctly following the diagnosis and procedure codes to document weight assessment and counseling for nutrition and physical activity. Remember that a nutritional evaluation and anticipatory guidance should be a part of the health check visit.

Record your effortsDocument BMI percentile and counseling for nutrition and physical activity annually. Make sure your records reflect:• Date of visit.• Weight and height.• BMI percentile, documented or plotted on age-growth

chart.• Counseling for nutrition and physical activity, indicated in

a checklist.

Code your services correctlyIt is an important critical aspect to code HEDIS® quality measures on claims. This helps reduce the amount of medical record requests and ensures a smoother, more efficient HEDIS process.

Use the following diagnosis and procedure codes to document weight assessment and counseling for nutrition and physical activity.

Weight assessment, nutrition counseling and physical activity (for those 3-17 years of age)Description ICD-10 codesBody mass index percentile Z68.51-Z68.54Counseling for nutrition Z71.3

Counseling for physical activity

Exercise counseling: Z71.82

Encounter for participation for sports: Z02.5

UWV-NL-0147-18

HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).

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Medical Policies and Clinical Utilization Management Guidelines updateThe Medical Policies and Clinical Utilization Management (UM) Guidelines detailed in the bimonthly update were developed or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. For markets with carved-out pharmacy services, the applicable listings below are informational only.

Note: • Effective November 1, 2018, MCG will be used for reviews, to include the use of customizations to certain

guidelines and Behavioral Health Care Guidelines (NEW).• Additionally, effective November 1, 2018, AIM Specialty Health® Proton Beam Therapy will be used for

clinical reviews.

Please share this notice with other members of your practice and office staff.

To search for specific policies or guidelines, visit http://www.unicare.com/medicalpolicies/search.html.

View the list of newly approved Medical Policies and Clinical UM Guidelines in the May 2018 update.UWV-NL-0132-18

Medical Policies Clinical UM Guidelines

On May 3, 2018, the Medical Policy and Technology Assessment Committee (MPTAC) approved several Medical Policies applicable to UniCare Health Plan of West Virginia, Inc. (UniCare).

On May 3, 2018, the MPTAC approved several Clinical UM Guidelines applicable to UniCare. The update details the guidelines adopted by the medical operations committee for the Government Business Division on April 19, 2018.

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Injection infliximab-dyyb, biosimilar (Inflectra) and infliximab-abda, biosimilar (Renflexis)Effective November 1, 2018, PA requirements will change for injectable/infusible drugs Infliximab-dyyb, biosimilar (Inflectra) and Infliximab-abda, biosimilar (Renflexis) to be covered by UniCare Health Plan of West Virginia, Inc.

PA requirements will be added to the following:• Injection, infliximab-dyyb, biosimilar,

(Inflectra), 10 mg (Q5103)• Injection, infliximab-abda, biosimilar,

(Renflexis), 10 mg (Q5104)UWV-NL-0140-18

Interferon beta-1aEffective December 1, 2018, PA requirements will change for injectable/infusible drug Interferon beta-1a to be covered by UniCare Health Plan of West Virginia, Inc.

PA requirements will be added to the following:• Interferon beta-1a — injection, 30 mcg (J1826)UWV-NL-0138-18

Prior authorization (PA) requirements

Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions, take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

To request PA, you may use one of the following methods: • Web: https://www.availity.com• Fax: 1-855-402-6983

1-844-487-9290 — Pharmacy• Phone: 1-866-655-7423

1-877-375-6185 — Pharmacy

Not all PA requirements are listed here. Detailed PA requirements are available to contracted and noncontracted providers on our provider website (www.unicare.com > Providers > State Sponsored Plan providers > West Virginia - Medicaid Managed Care > Authorization and Preservice Review > Precertification Look Up Tool [PLUTO]). Providers may also call us at 1-866-655-7423 or 1-877-375-6185 (Pharamacy) for PA requirements.