Case & Disease Management Programs: Partnering to Help Your Patients & Our Members

In this issue:

Spring 2013

PROVIDER BULLETIN

The Alliance Case Management and Disease Management (CM & DM) programs help manage care for members with medically complex and/or chronic conditions. By coordinating services that support providers’ ongoing care, we can better ensure improvement of patient outcomes and member satis-faction. CM & DM programs are FREE to Alliance members.

CM & DM teams include: • Registered Nurses • Social Service Professionals • Health Coaches • Psychosocial Professionals • Community Outreach Specialists

CM & DM teams can work with provider practices to: • Assist in supporting management of your patients’ health • Help members navigate through the health care system • Motivate your patients to be active in their health decisions • Serve members as a liaison, to access community and

health plan resources • Collaborative for appropriate care coordination

Case Management provides services to members with complex health problems. Participation in the case man-agement program is voluntary. Members can discontinue participation in the program at any time. The Alliance uses internal data and accepts referrals from members/caregivers, practitioners and providers, and Alliance staff to identify members for case management services. The Case Manage-ment team evaluates each referral to determine whether the member is appropriate for inclusion in the program.

Disease Management provides services to children (ages 5-11) with asthma, and to adults with diabetes. Members with asthma or diabetes are identified through our claims/encounters data and are automatically enrolled in the appro-priate program to receive, on a regular basis, health educa-tion and/or telephonic coaching. Members at the highest risk are enrolled in Disease Management to find out if they need extra help with their health care. Members can choose to stop participating at any time.

To learn more aboutCM & DM or make a referral: Contact the CM & DM department at 1-877-251-9612 orfax: 510-747-4130,Monday-Friday, 8 a.m.–6 p.m.

Provider Profile Updates 2 Formulary and Rx Management 6 Preventive Health Guidelines 2 Formulary Updates 7 Provider Survey Results 3 Claims Corner 8 Health Education Resources 3 Interpreters & Transportation 9 Safe Jobs for Youth 4 Rights & Responsibilities 9 Shaken Baby Syndrome 4 Fraud, Waste, & Abuse 9 Access & Availability Standards 5 Contact Info 10 Advair Conversion Cancelled 5 Protect PHI 11

Notes

Please review your physician, clinic or hospital profile online regularly. With accurate information on our website, your patients and our members are able to choose the physician that best matches their preferences.

Our provider portal allows you real time access to review and securely update information about your practice, including:

Physician and group name Gender Specialty Board certifications Office location(s) Languages spoken Hospital and medical group affiliations Accepting new patients

Others ways to change your profile are by: Email: providerservices@alamedaalliance.orgFax: 1-877-747-4508 Mail: Provider Services, Alameda Alliance for Health, 1240 South Loop Rd, Alameda, CA 94502

Update Your Provider Profile Online

The Alliance has updated evidence-based, clinical, behavioral and preventive health guidelines, now available at www.alamedaalliance.org/providers/medical-management/clinical-guidelines/.

We use clinical practice guidelines to help providers make decisions about appro-priate health care for specific clinical circumstances. These clinical practice guide-lines are also used by the Alliance in related programs, such as Disease and Case Management. Practice guidelines are developed from scientific evidence or a con-sensus of health care professionals in the particular field.

The Alliance’s Health Care Quality Committee (HCQC) reviews and adopts these clinical, behavioral, and preventive health guidelines. The guidelines define stand-ards of practice as they pertain to improving health care quality for major diseases/diagnoses, as well as preventive care. Practice guidelines are reviewed and updat-ed at least every two years, and more frequently when updates are released by the issuing entity.

The guidelines are not intended to replace clinical judgment, but are made availa-ble to assist Alliance providers with decision making about a range of clinical con-ditions.

If you would like a hard copy of the guidelines, please contact the Provider Ser-vices department at 510-747-4510.

Now Online – The Alliance’s Clinical, Behavioral, & Preventive Health Guidelines

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These guidelines are posted on the Alliance’s website in PDF format for easy downloading:

Acute Respiratory Tract Infection Guideline Asthma Clinical Practice GuidelineBehavioral Health Guide-linesDiabetes Care Guideline Hypertension Guideline Major Depression in Adults in Primary Care Guideline Adult Preventive Guidelines Children and Adolescent Preventive Guidelines Perinatal Guidelines

Please take a few minutes to verify your information and let us know if anything has changed.

www.alamedaalliance.org/Provider

(Provider Connection)

The just-updated Provider Directory of Health Education Resources is available. The Directory lists referrals ranging from diabetes to domestic violence, from breastfeeding to asthma, and parenting, and more. All programs are FREE to Alliance members. Linda Ayala, Alliance Health Educator, at 510-747-6038 or layala@alamedaalliance.org has resources for your patients’ health and well-being.

Health Education Resources – New Referral Lists

The Myers Group (TMG), a National Committee for Quality Assurance (NCQA) Certified Survey Vendor, was selected by the Alliance to conduct its 2012 Provider Satisfaction Survey. Information obtained from these surveys allows the Alliance to measure how well we are meeting our providers’ expectations and needs. The results are also used to identify opportunities for improvement.

Here are the top dozen 2012 results:

Source: The Myers Group Provider Satisfaction Survey, 2012. The 2011 TMG Medicaid Book of Business is a bench-mark containing data from eligible Provider Satisfaction Surveys for which TMG collected data in 2011. The benchmark is comprised of Primary Care Physicians, Specialists, and Behavioral Health Clinicians and includes data from 57 plans encompassing 19,710 respondents. Methodology/2012 Alliance Survey: A total of 162 surveys were completed (92 mail surveys and 70 phone surveys), yielding a response rate of 13.1% for the mail data collection component and 32.4% for the phone data collection com-ponent.

Your Feedback is Important – Let us know how we can better meet your needs If you have questions regarding this survey, or comments, or would like additional information, please contact the Provider Services department at 510-747-4510.

Results – 2012 Alliance Provider Satisfaction Survey

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Practitioners’ Satisfaction with… Alliance Rate All Other Health Plans Rate

Medicaid Book of Busi-ness Rate

Call Center/Member Services Staff 52.1% 38.3% 41.9%

Provider Relations 47.9% 33.9% 39.6%

Continuity/Coordination of Care 42.0% 34.5% N/A

Network 31.9% 32.7% 28.0%

Utilization & Quality Management 40.4% 28.2% NA

Finance Issues 27.8% 24.1% 29.1%

Pharmacy and Drug Benefits 30.2% 24.2% 23.3%

California Timely Access 77.7% NA NA

Overall Satisfaction and Loyalty 86.4% NA 80.4%

Recommend to other physicians’ practices 87.2% NA 83.3%

Recommend to other patients 88.8% NA 83.3%

Overall Satisfaction 83.2% 84.6% 74.4%

Join the Alliance and the Forum for Perinatal Health to prevent Shaken Baby Syndrome (SBS). This violent shaking of a baby by the shoulders, arms or legs, can cause permanent injuries such as blindness, brain damage, disability, or even death. Inconsolable crying is a primary trigger for shaking a baby. It takes only one SBS event to result in tragedy, but SBS is preventable. A new brochure to help Alliance providers and their staff help expecting and new parents is now available: Never Shake a Baby! To receive FREE copies for your practice from Alliance Health Programs, contact Linda Ayala, Health Edu-cator, at 510-747-6038. Language options include English, Spanish, Chinese, and Vietnamese. Online copies are available at: www.acphd.org/pregnancy/after-baby-is-born.aspx

This brochure helps parents and other caregivers make good decisions. They will learn: the risks of shaking a baby (in clear, non-judgmental language); how to calm a crying baby; and where to link with Family Paths for 24/7, confidential parent support.

Shaken Baby Syndrome – New Tool to Prevent Tragedy

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Safe Jobs for Youth – Talk to your Teen Patients about Work!

Millions of adolescents in the United States work. Sadly, each year an estimated 146,000 youth under age 18 are injured on the job and approximately 30 die from work-related injuries.

As a health care provider, you have an excellent opportunity to counsel your teen patients during the high risk transition from childhood to adulthood. You can provide them with information, promote safe work practices, and encourage them to know their rights, ask questions, and to speak up when there is a problem. Thank you for helping teens stay safe at work!

Tools for Action: Talking to Your Teen Patients about Work – this tip sheet provides questions, talk-ing points, and resources. Visit www.youngworkers.org or call 1-888-933-TEEN for more information/resources on young workers’ health and safety.

The Alliance constantly works to ensure we maintain a network that meets the needs of all our members. The road to success is through our partnership with network providers. To help us make sure standards are reached, please continue to help us achieve our mutual objective–an amazing network delivering the best quality care for our member/patients–by assisting with these goals:

Goal: Access Standard If you work with colleagues who might be interested in contracting with the Alliance, please get in touch with Provider Ser-vices at providerservices@alamedaalliance.org or 510-747-4510. We are always looking to contract with primary care providers and are currently actively recruiting the following specialty care providers:

OBGYN (Southern County) Dermatologist Rheumatologist Neurologist Orthopedic Surgeons/Ortho hand Surgeons Pain Management

Goal: Availability Standard Help us meet availability standards by ensuring that your office covers those types listed below. Each is important; a top priority would be your office blocking for a certain number of appointments, daily, for emergent/urgent care needs. If you have any questions, please contact Provider Services at providerservices@alamedaalliance.org.

In January 2013, the Alliance informed affected providers about a conversion from Advair Diskus®/Advair HFA® to Dulera® Metered Dose Inhaler. The conversion was initially set for April 1, 2013. This

conversion has since been cancelled and Advair Diskus® and Advair HFA® remain the pre-ferred combination Inhaled Corticosteroid/Long-Acting Beta Agonist (ICS/LABA) on the Alli-ance Medi-Cal and Group Care formulary. Members who were switched to Dulera® as part of this conversion may remain on Dulera. For new therapy please continue prescribing Advair. Please note that ICS/LABA inhalers are on the Alliance formulary as part of a Step Therapy requirement, necessitating trial and failure to Inhaled Corticosteroids (QVAR®), leukotriene receptor antagonist (Singulair®), and long-acting anticholinergics (Spiriva®).

Ensuring Our Best Network: Help Us Meet Access & Availability Standards

Advair Conversion: Cancelled

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Type of Care Standard

Emergency Immediate; 24 hours a day, 7 days a week

Urgent Prior Authorization—Within 96 hours of requestNo Prior Authorization—Within 48 hours of the request

Routine Within 10 business days of the request

Preventive Within 10 business days of the request, not to exceed 30 calendar days

Specialty Within 15 business days of the request

Prenatal Urgent Prenatal—Same dayInitial Prenatal Visit—Within 2 weeks of the request

Ancillary (Non-Urgent) Within 15 business days of the request

The Alliance’s clinical pharmacy management program and procedures are designed to promote rational drug use based on published medical literature and community standards of care. The Alliance Pharmacy and Therapeutics (P&T) commit-tee meets each quarter to establish and implement these pharmaceutical management procedures. Committee members include the Alliance Chief Medical Officer or designee, the Alliance Director of Pharmacy, licensed practicing pharmacists, and licensed practicing physicians from the community.

Criteria used by the P&T committee to adopt or revise pharmaceutical management procedures, include: provider recom-mendations; cost-effectiveness; drug utilization; experience; evidenced-based literature; and national guidelines. All to-gether, these factors help determine: drugs and drug classes preferred and covered on the formulary; a process available to members and providers to obtain non-covered drugs (either as a prior authorization or exception); and limits to drug ac-cess in certain classes.

The Alliance Formulary: Five Drug Dispensing Categories 1. Formulary Drugs: covered by the Alliance, though each may have its own restrictions and limitations including:

mandatory generic substitution when available; quantity limits; step therapy; and age/gender restrictions. 2. Code 1 Restricted Drugs: allows for faster access to non-formulary drugs, bypassing the prior authorization of

exception process. The dispensing pharmacist can enter a Code 1 override at time of dispensing – after confirm-ing that specific criteria have been met.

3. Therapeutic Interchange: promotes rational pharmaceutical therapy by substituting the requested drug with a different one of comparable effectiveness.

4. Drugs Requiring Prior Authorization: providers can request a prior authorization by submitting a Medication Request Form (MRF) to MedImpact per the prior authorization protocols.

5. Drugs Requiring Exception: similar to a prior authorization, except the Alliance does not have medication review criteria to guide the reviewer, or the requested drug exceeds the scope of coverage. Rather, approval will be based on evidence of medical necessity, on a case-by-case basis. Providers can request an exception authoriza-tion by submitting a Medication Request Form (MRF) to MedImpact per the exception protocols.

Formulary & Pharmaceutical Management – the Alliance Pharmacy Program

The formulary is subject to revision, to align with continuous advances in pharmaceutical treatments, new safety findings, and the needs of members. Providers may request formulary changes for P&T Committee review by using the “Request for Formulary Review” form available on the Alliance website.

Resources for Providers: Alliance Provider Manual www.alamedaalliance.org/providers/provider-manualComprehensive formulary www.alamedaalliance.org/providers/pharmacy-drug-benefits/ – The Medi-Cal and Alliance Group Care formularies are listed under “Alameda Alliance for Health”; find the CompleteCare formulary under “Alliance CompleteCare” www.epocrates.com (click freeware for an account and access to the Alliance formulary) MedImpact (24/7) for inquiries on any of the above formulary categories or to submit a verbal prior authorization or exception at 1-800-788-2949. Providers can fax an authoriza-tion form to 1-858-790-7100.

Rx

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Page 7 PROVIDER BULLETIN

P&T Decisions Effective April 30, 2013

TEMAZEPAM RESTORIL ADD 22.5 MG AND 7.5 MG TO FORMULARY WITH PA

ATORVASTATIN LIPITOR REMOVE CODE 1; ADD TO FORMULARY WITH STEP EDIT LOVASTATIN 40;PRAVASTATIN 40, 80; SIMVASTATIN 40,80

GLYBURIDE DIABETA/MICRONASE ADD AGE EDIT FOR 65 AND OLDER

NATEGLINIDE STARLIX ADD TO FORMULARY WITH STEP EDIT METFORMIN OR SULFONYLUREA

CLOZAPINE CLOZARIL; FAZACLO ADD TO FORMULARY FOR IHSS WITH QUANTITY LIMIT OF 6/DAY

ZIPRASIDONE GEODON ADD TO FORMULARY FOR IHSS WITH QUANTITY LIMIT OF 2/DAY

PALIPERIDONE INVEGA ADD TO FORMULARY FOR IHSS WITH QUANTITY LIMIT OF 2/DAY

QUETIAPINESEROQUEL

SEROQUEL XRADD TO FORMULARY FOR IHSS WITH QUANTITY LIMIT OF 2/DAY

OLANZAPINE ZYPREXA ADD TO FORMULARY FOR IHSS WITH QUANTITY LIMIT OF 1/DAY

LUTICASONE FLOVENT DISKUS FORMULARY WITH STEP EDIT QVAR AND ADVAIR DISKUS

PRIOR AUTHORIZATION GUIDELINES UPDATES

TOPICAL NSAIDSDICLOFENAC (SOLARAZE)STEP THERAPY (VARIOUS)ARIPIPRAZOLE (ABILIFY)

INCRETIN MIMETICS (BYETTA; VICTOZA)

INSULIN DELIVERY SYSTEMS (APIDRA SOLOSTAR; LANTUS SOLOSTAR; HUMALOG KWIKPEN; NOVOLOG; NOVOLOG RAPID

TOPICAL TACROLIMUSM (PROTOPIC)

TOPICAL PIMECROLIMUS (ELIDEL)

TESTOSTERONE TOPICAL TESTOSTERONE; TESTOSTERONE CYPIONATE; TESTOSTERONE ENANTHATE

ESTROGEN PATCHES ALORA; CLIMARA, VIVELLE/VIVELLE DOT

EPOETIN ALFA (EPOGEN;PROCRIT)

DARBOEPOETIN ALFA (ARANESP)

EZETIMIBE (ZETIA)

ATORVATATIN LIPITORATOMOXETINE (STRATTERA)

Generic Name Brand Name Committee Actions

The P&T Committee reviewed the efficacy, safety, cost, and utilization profiles of the following therapeu-tic categories at the 3/7/13 meeting: hypnotics/insomnia; statins; psoriasis topical agents; oral agents for the treatment of diabetes; and atypical antipsychotics. The Committee approved these modifications to the Alliance’s Medi-Cal, Healthy Families, and Alliance Group Care formulary:

FormularyUpdate

*Note: Drugs removed from the formulary will NOT be grandfathered for utilizing members unless noted otherwise under “Committee Actions.”

Paper & Corrected Claims: Providers may submit these to the following address. Corrected claims must be clearly marked as such to avoid denials as duplicate claim submission.

Alameda Alliance for Health, ATTN: NOPD Unit-Claims Department P.O. Box 2460, Alameda, CA 94501-0460

Requests for Payment Reconsideration: Providers may contact Claims Customer Service at 510-747-4530, Monday–Friday, 8:30 a.m. –4 p.m. Or submit a written Notice of Provider Dispute (NOPD) Form to the above address.

Timely Filing Guidelines: Contracted providers must submit clean claims within 180 calendar days post-service, or– if other coverage exists –postdated from Explanation of Benefits (EOB). Corrected claims must be submitted correctly for reconsideration of payment within 180 days of the date of the origi-nal denial by the Alliance. Request of Reconsideration or Claim Disputes must be received by the Alliance within 365 days after the last date of action that led to the dispute. Exceptions to the timely filing limits can be made with submission of Proof of Timely Filing (POTF) documentation. Acceptable POTF documentation includes:

Copy of the RA or EOB from the primary payer indicating the date of resolution (payment, date of contest, denial, or notice) when the claim was denied. Certified mail receipt indicating date received by the Alliance. Copy of the Alliance’s EDI Error Report for claims originally submitted electronically. Documentation demonstrating extenuating causes for the delay. NOTE: Computer printouts are not acceptable.

Problem Solver – Denial of the Quarter: NOREF: NO REFERRING PROV IN BOX 17 ON CMS1500; RESUBMIT CLAIM

For Specialist-to-Specialist referral claimsEnter the referring provider’s name in the Name of Referring Provider or Other Source field (Box 17), and NPI in the NPI field (Box 17B) on the CMS-1500 claim form.

For EDI claimsSubmit referring provider name and NPI in segment NM1*DN*1 of the 837P claim file. Claims submitted without referring provider name or NPI on claim will be denied.

For more, please see your Alliance Provider Manual at www.alamedaalliance.org or call Provider Services at 510-747-4510.

Claims Corner

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Non-emergency transportation maybe covered when the member needs to go to a scheduled medical appoint-ment and return home.

For an in-office, face-to-face interpreter: call Member Services at 510-747-4567, Monday-Friday, 8:00 a.m.-5:00 p.m.

For telephone and after-hours phone interpreter service: call 1-866-948-4149, 24 hours a day, sev-en days a week.

The Alliance offers free interpreter services and medical transpor-tation. Please remember to recommend that members use profes-sional medical interpreters and not family members or friends. If a member declines the use of a professional medical interpreter please note that in their medical record.

Alliance Member Rights and Responsibilities

Free Language Service & Medical Transportation

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The Alliance is committed to complying with all applicable federal and State laws addressing false claims, including the Federal False Claim Act, the California False Claims Act and the Deficit Reduction Act of 2005.

The Alliance fosters a culture that promotes prevention, detection, and resolution of situations that do not conform to these laws. If you have concerns about possible fraud, waste, or abuse,

possible unethical business practices or potentially illegal activity regarding our health plan, our providers, vendors, or members, please report this information by contacting:

Alameda Alliance for Health Compliance Hotline 1-855-747-2234 Alameda Alliance for Health Compliance department: compliance@alamedaalliance.orgFor Medi-Cal: Call the Department of Health Care Services Medi-Cal Fraud Reporting Line:1-800-822-6222 For Medicare, call the US Department of Health and Human Services Office of Inspector General:

1-800-447-8477 or the Centers for Medicare and Medicaid Services: 1-800-633-4227.

Fraud, Waste, & Abuse

Alliance members have rights and responsibilities. We encourage you to be familiar with our members’ rights and respon-sibilities and we expect that you will abide by these rights.

The complete Alliance’s Member Rights and Responsibilities statement is posted on the Alliance website at alamedaalli-ance.org/members/member-materials/. If you would like a paper copy of the statement, please contact Provider Services at 510-747-4510.

CONTACT INFORMATION

Alameda Alliance for Health Offices

Headquarters: 510-747-4500 1240 South Loop Road, Alameda, CA 94502

Downtown Oakland: 877-585-7526475 14th Street, Suite 730, Oakland, CA 94612

Ed Roberts Campus: 510-747-6100 Adeline Street, Suite 160, Berkeley, CA 94703

We’re on the Web:www.alamedaalliance.org

Alliance Providers Phone Alameda County Behavioral Health 800-491-9099Children First Medical Group 510-428-3154Community Health Center Network 510-297-0200MedImpact (pharmacy benefit manager) 800-788-2949Liberty Dental (ACC Only) 888-703-6999Denti-Cal 800-322-6384

March Vision Care 888-493-4070Optum Behavioral Health (Call Center): 800-999-9585

physician consultation 800-292-2922member referral 800-999-9585

Quest Diagnostic outpatient lab services 800-288-8008

Medi-Cal for Families 800-880-5305

Alliance Department Phone FaxAuthorizations Mon-Fri 8:30 a.m.-5 p.m. (provider use only) 510-747-4540 877-747-4507

Claims 510-747-4530, option 4 877-747-4506

Eligibility (24-hour automated line) 510-747-4505

Member Services Mon–Fri, 8–5 (eligibility, provider assignment, schedule interpreters)

510-747-4567 877-747-4504

Pharmacy Services 510-747-4541 877-748-4524

Provider Services 510-747-4510 877-747-4508providerservices@alamedaalliance.org

Compliance 855-747-2234

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Protect the PHI of Your Patients!The privacy of patients and their Protected Health Information (PHI) is a responsibility we all share. The Health Information Portabil-ity and Accountability Act (HIPAA) clearly outlines how providers can use and disclose PHI. Additional federal and California laws have been enacted to: cover release of information; mandate that information be protected; create new breach notification rules; and set civil/criminal penalties and fines for inappropriate release of PHI.

Written patient permission is required for most PHI uses and disclosures. However, PHI (the minimum necessary) may be used and disclosed for the purposes of treatment, payment, and health care operations.

Here are a few of the ways you and your office can protect patient/member privacy: Keep PHI actively in mind and in your staff policies Provide ongoing training for yourself and staff Develop a process to respond to privacy issues that arise (including notifying the Alliance of any breach) Limit transporting PHI out of your office Use secure email when communicating about members with someone outside your office Store and lock up all documents containing PHI Secure your office computers from any unauthorized access Shred physical documents that contain PHI as soon as no longer needed Keep appointment and registration sheets away from public view Never text PHI

For more about PHI and HIPAA compliance, visit www.hhs.gov. For answers about how to improve security and storage of patient PHI, contact the Alliance Provider Services department at 510-747-4510. Access the Alliance Notice of Privacy Practices at www.alamedaalliance.org/~/media/files/modules/global/noticeofprivacypracticesdhcsdmhcinal.pdf.

Alameda Alliance for Health

1240 South Loop Rd

Alameda, CA 94502

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