Fall 2016
This is a Johns Hopkins HealthCare Publication
Genetic Testing
The Basis of Individualized Medicine Hopkins Across the Board is a newsletter for Priority Partners, Employer Health Programs and Johns Hopkins US Family Health Plan network providers.
table of
contents 04 Genetic Testing
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EHP
USFHP
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08 Resources for Members with Diabetes
10 …and EHP Helped!
EHP
11 Adolescent Well Visits
USFHP
Our product lines include: PP = Priority Partners EHP = Employer Health Programs USFHP = Johns Hopkins US Family Health Plan
Hopkins Across the Board is published quarterly for Priority Partners, Employer Health Programs (EHP), and Johns Hopkins US Family Health Plan network providers. It is produced and distributed by Johns Hopkins HealthCare’s (JHHC) Marketing and Communications Department. JHHC President–Patty Brown; Chief Operating Officer–Karen Eskridge; Priority Partners Acting Chief Executive Officer–Ed Kumian; USFHP Vice President–Mary Cooke; Provider Relations Associate Vice President –Dina Goldberg; EHP Senior Director–Michelle Ross-Gavin; Marketing and Communications Director–Karen Dixon; Marketing and Communications Copywriter– Kris Moody. If you have questions or suggestions, or would like to submit an article for publication, please contact the editor, Donna Chase, at
[email protected].
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medical director’s corner
GENETIC TESTI N The Basis of Individua G: lized Medicine A New Era
Doctors have always rec ognized that every patien t is unique, and doctors have always tried to tailor their treatm ents as best they can to individuals. You can match a blood tra nsf usion to a blood type — that was an important discov ery . Wh at if matching a cancer cur e to our genetic code wa s jus t as easy, just as standard? Wh at if figuring out the rig ht dose of medicine was as simple as taking our temperatu re?
Pharmacogenomics, the study of how genes affe ct a person’s response to drugs, is an emerging field in science and medicine that allows ph ysicians to use the genetic information of patients in order to aid in clinical decision-maki ng, is just one application of NGS. By combining the science of how – President Barrack Ob dru gs work (pharmacology) ama, January 30, 2015 with the science of under standing the human genome (genomi More than a year ago, cs), clinicians are able to the President announce tak d e the an lau ind nch ividualized approach wh of the Precision Medic en treating patients. Th ine Initiative to accele e rat e a effe new ctiv eness of genetic testing era of medicine that del is based on analytic validi ivers the right treatment ty, at the clinical validity (sensitivi right time to the right ty, specificity, and positi person with regards to ve and a pat ien neg t’s ativ e predictive values of tes genes, health history, life t), and clinical utility. style, and environment . Ut ilizing pharmacogenom Genetic testing is a tec ics information enable hnique used to examine s an physicians to prescribe individual’s DNA. The drug and treatment op field of genetic testing tio ns that has ma ximize the benefits of tre expanded rapidly durin atment while simultane g the past 20 years, evo ou lvin sly g mi to nimizing the risk of sid produce faster sequencin e-effects in patients. Ph g techniques at a lower arm acos t. cog enomics has the poten Sanger sequencing techn tial to limit trial-and-er ology was developed in ror when the 1970s administering new or mu and was the technique ltiple drugs to patients. used to complete the Hu ma n Genome Project. Interpretation of geneti c testing results crosses over many disciplines within medicine. Laboratory Next Generation Sequen sci entists, cing (NGS) pathologists, genetic cou nselors, physicians, and has developed during nurses all collaborate to ensure acc urate interpretation of the past decade and has results and been to discuss treatment op tions for patients. largely responsible for the rapidity The Medical Policy tea with which genetic testin m at Johns Hopkins He g has althCare (JHHC) has been collab grown. Rather than ref orating with academic erring to clinicians to improve health and a single testing method, treat disease. We are als NGS o developing and rewriting policies refers to a group of seq including both Pharm uencing aco gen omics and Genetic Testing Po technologies (Muzzey, licies to address this ini 2015). tia tiv e. We will be moving tow NGS involves sequencin ard what JHHC presid g ent, Patty Brown, has described as millions of DNA fragm a “collaborative partne ents in rship with Johns Hopkins Medicine parallel by incorporatio toward an academicallyn of based, integrated health care fluorescently labeled DN delivery system.” A bases. The end result is Through collaborative that public and private effort s, the the cost of sequencing Precision Medicine Ini has tiative will leverage adv ances in dropped dramatically wit genomics, emerging me h thods for managing and analyzing a cor responding increase large data sets while pro a medical tecting privacy, and hea Dr. Mark Fracasso is ins lth spe ed. These technical information technology pk to accelerate biomedical director at Johns Ho rnie, MD. discoveries. Bu improvements coupled It’s already transforming HealthCare in Glen the way diseases such as cancer with our rapidly increa and mental health con sing ditions are being treate understanding of the con d, and family members are helping on sequences of genetic variation to me e another address geneti dicine have made it fea c risk . sible to greatly For additional informati expand genetic testing. on, please visit www.w hitehouse. gov/precision-medicin e 4 | Hopkins Across the Board
BUILDING THE BRIDGE FOR SUICIDE PREVENTION Providers serve as a first line of defense for suicide prevention. Providers who counsel patients having suicidal thoughts may reduce the patient’s anxiety and/or guilt, thus allowing providers to create a safe environment. In turn, providers would then have opportunity to develop appropriate treatment plans for their patients.
Developing Mental Health Partnerships
•P atients presenting with depression need professional resources. Developing partnerships with mental health providers will provide adequate referral protocols and resources. Prevention of suicide depends on the ability of a patient receiving proper care in a timely manner.
Suicide affects all ages, backgrounds, racial and ethnic groups, and has no geographical boundaries. It is estimated that yearly 38,000 Americans will die from suicide and 465,000 will attempt suicide. The highest risk is with the elderly population which has a rate of 15.4 suicides per 100,000. Providers can use the following key elements to reducing suicide among patients by:
• I mprove access to care. Identify community resources and/or individualized treatment services (school, work, or home based services).
•R eal-time patient care that can offer stabilization to the mental health and well being of the patient.
Educating Clinicians and Staff
•P roviding a resource to the patient can assist the patient’s abilities to reach out for help.
• Include the patient’s family. The family often serves as the core support system and may assist engaging patient into care.
•C reate safety planning and coping strategies that will reduce risk of suicide.
• I t is important that all clinical staff have training and educational resources in identifying the signs of suicide.
•P HQ9 is a tool that provides a depression-screening questionnaire. The tool is a great resource to provide a brief and useful assessment. The tool can be used multiple times to evaluate changes of depression within the patient and provide a good alert system for providers to provide adequate referrals.
•R eview patient’s personal and family history for suicide risk factors to include mental health diagnosis, previous attempts and/or suicidal ideations in past and present. History of prior attempt is the greatest risk factor.
• Provide an assessment to screen all patients. This should include adolescent populations. Early Periodic Screening Diagnosis and Treatment (EPSDT) recommend mental health and substance abuse screenings beginning at 12 years of age.
•H igh-risk patients presenting in office may need immediate attention requiring hospitalization. Providers should identify protocols and guidelines for involuntary hospitalization for patients presenting in office with current suicidal ideation with intent (active planning).
Providing Patient Education and Resources
More information can be obtained from the Substance Abuse and Mental Health Services Administration (SAMHSA) National Suicide Prevention Lifeline online at www.samhsa.gov or by calling 800-273-TALK (8255).
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IF NPI IS INCORRECT…. . Effective October 1, 2016, claims submitted to Johns Hopkins HealthCare (JHHC) with the incorrect National Provider Identifier (NPI) type will be denied. NPI is a 10-digit number that is used to identify providers in all standard HIPAA transactions. There are two types of health care providers in terms of an NPI number: • Type 1 NPI is for health care providers who are individuals, including physicians, dentists, and all sole proprietors • Type 2 NPI is for health care providers who are organizations, including physician groups, hospitals, nursing homes, and individual providers who incorporate and become a corporation To obtain a Type 1 NPI or Type 2 NPI, providers must apply through the National Plan and Provider Enumeration System online at https://nppes.cms. hhs.gov/NPPES. 6 | Hopkins Across the Board
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The NPI policy can be found online at: www.hopkinsmedicine.org/johns_hopkins_healthcare/ downloads/updated_files/National%20Provider%20 Identifier%20effective%2010.1.pdf
PRE-AUTHORIZATION FOR GENETIC TESTING To assist you in understanding our pre-authorization guidelines, Johns Hopkins HealthCare (JHHC) has a genetic testing policy in place. These easy to reference guidelines clearly outline the pre-authorization requirements for genetic testing. This information pertains to Priority Partners, Employer Health Programs (EHP) and Johns Hopkins US Family Health Plan (USFHP) members and can be found at www.jhhc.com under the Provider tab, Resources and Guidelines. Please follow the Hold Harmless language in your JHHC Participating Provider Agreement under the following section: IV. Compensation, Section C. Hold Harmless. JHHC will continue to promote and provide training to providers who may need assistance with the preauthorization guidelines for the genetic testing policies.
FROM THE PHARMACY A variety of pharmacy information and resources are available to you on the JHHC websites for each line of business. This includes information related to the pharmacy formulary, pharmaceutical restrictions or preferences, requesting a benefit exception, step therapy, generic substitution and other pharmacy management procedures. The pharmacy formularies are specific to each plan and are updated regularly to include new medications and the latest safety information. For additional information on the formularies, please use the plan specific links listed below or contact the JHHC Pharmacy Department at 888-819-1043.
For Priority Partners hopkinsmedicine.org/johns_hopkins_healthcare/ providers_physicians/our_plans/priority_partners/ pharmacy.html
For Employer Health Programs hopkinsmedicine.org/johns_hopkins_healthcare/ providers_physicians/our_plans/ehp/pharmacy_ formulary/index.html
EHP
USFHP
For Johns Hopkins US Family Health Plan hopkinsmedicine.org/johns_hopkins_healthcare/ providers_physicians/our_plans/usfhp/pharmacy.html
BEHAVIORAL HEALTH Care for a non-life-threatening emergency is required within six (6) hours for both new and existing patients. Please note that it is acceptable for providers to refer members with non-life-threatening behavioral health situations to the emergency room.
HealthLINK The electronic age is here, and we have tools to make your life easier as a provider. HealthLINK@Hopkins is a secure, interactive portal for access to claims, referrals, authorizations, member eligibility, and benefit information. HealthLINK@Hopkins helps eliminate paper claims by submitting your claim electronically. This cuts cost and you'll receive payment faster. Sign up now by visiting www.jhhc.com.
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RESOURCES FOR MEMBERS WITH DIABETES Johns Hopkins HealthCare offers care management services for our members with diabetes. Our care managers collaborate with the member and their various providers to coordinate a treatment plan and help them to better understand their condition. Our goal is to support and encourage the member to stay engaged in their plan of care by establishing a relationship through telephonic communication, educational information, reminders, and follow-ups. Providers wishing to initiate care management services can either e-mail
[email protected] or call 410-762-5206 or 800-557-6916. Voicemail messages received after normal business hours will be addressed the following business day. All referrals must include date of birth, identification number, diagnosis, and patient needs. Our health education team also offers free classes for members focused on diabetes.
Pre-Diabetes and Me A 90-minute workshop for adults - teaches how to prepare a healthy plate, count carbohydrates, add daily exercise into their life, and effectively work with their provider to prolong or prevent a diabetes diagnosis.
Living Well With Diabetes A five-week program for adults - teaches members about the importance of healthy eating and exercise, and how to recognize and prevent complications of diabetes and understand the relationship between stress, diabetes, and depression.
Diabetes Self-Management Program A six-week program for adults sponsored by Stanford University - provides members with tools to self-manage their diabetes through healthy eating, exercise, and taking medication as prescribed. Members will also set goals and develop weekly action plans.
Diabetes Mapping A four-week program - teaches adults the basics of diabetes, how to monitor and control their blood sugar, nutrition, and the importance of medication management. Please encourage your patients, our members, to take advantage of these valuable resources. Members can call 800-957-9760 or email
[email protected].
GOOD NEWS! Our redetermination challenges have been greatly reduced. Maryland Health Connections (MHC) has had several system upgrades that have decreased the long lines and waiting at the connector entities and the local health departments.
Auto Renewal
EVS Upgrade
One of the main system upgrades through MHC has been the Auto Renewal Process. Members who are unable to be auto renewed are notified and have the opportunity to go to MHC or a connector entity to reapply for benefits. The average auto renewal rate is over 60 percent. The auto renewal capability allows recipients (Priority Partners members) to be automatically renewed unless there are issues in verifying their information such as citizenship or income.
When contacting the Eligibility Verification System (EVS) for Priority Partners members, providers may see a “redetermination date” (if checking online) for the member. Providers can use this information to advise members that they will receive a notice regarding the renewal process for Medical Assistance benefits. This notice may require the member to take certain actions to maintain their coverage if they are not auto renewed.
Updated Demographic Information
Find the updated EVS User Guide at:
Priority Partners members no longer have to process a new application in MHC or report to the local Department of Social Services (DSS) office that their address has changed. They can access their account online to change their information. Having members use the portal to change their address, phone number, or other demographic information, has greatly reduced calls to the MHC Call Center.
https://mmcp.dhmh.maryland.gov/docs/EVS_Brochure_ May2016.pdf
BREAST CANCER AWARENESS To help improve breast cancer screenings among Priority Partners members, we will host breast cancer screening “clinic days” for members 52 years or older. No referrals are needed. Round trip transportation will be offered, and members will receive a $25 Visa gift card once they’ve been screened. To schedule a visit for your patients, our members, to our “clinic days,” please call toll free 844-288-9593.
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A DIABETES DISCOVERY, AND EHP HELPED
IMPORTANCE OF ADOLESCENT WELLNESS VISITS
An Employer Health Programs (EHP) member wasn’t prepared for a diagnosis of diabetes.
With the start of a new school year, we would like to remind our provider community that the Johns Hopkins US Family Health Plan (USFHP) covers one comprehensive wellness evaluation and a follow up visit for adolescent’s age 12 to17.
It was a new world for Yvonne. She needed help, so she enrolled in the care management program. Rebecca Cirri became her care manager and advised Yvonne on the health care services that she needed, worked with her to schedule appointments, answered her questions, and educated her on eating right and exercising.
Adolescent well visits promote healthy habits and offer the opportunity to identify any risky behaviors. Comprehensive wellness visits should include, as appropriate: •D ietary Assessments and Nutrition Counseling • Physical Activity and Exercise Advice • Cancer Surveillance • Safe Sexual Practices •T obacco, Alcohol, and Substance Abuse Education • Accident and Injury Prevention • Dental Health Advice • Stress Management • Bereavement • Suicide Risk Assessment
“She’s excellent,” Yvonne said. “Very helpful. Very concerned. And I needed that. That helped me a lot, to know that somebody is really concerned about my health.” Care managers have regular telephonic communication with the members they serve. Rebecca said her job is to support the member and their medical care. “I always tell them that I’m here to help them understand their disease better so they’re more comfortable with it,” Rebecca said. “The whole goal is to get the member better at managing their chronic condition.” Yvonne stated that her care manager has been far more than just a source of support; that Rebecca has been a key part of her diabetes care, and without her, said her health would not be as good. “If I didn’t have Rebecca as my care manager to guide me and instruct me and give me all the information that I need, I’d be in bad shape. I wouldn’t be as successful as I am today. I thank God for her. She’s excellent. She’s outstanding.”
EHP member Yvonne Baker has control of her diabetes thanks to EHP care management and health coaching programs. “I hope that more people take advantage of it,” she said, “ because I thank the Lord for those programs."
Care management is a free service for EHP members. Members can self-refer by calling 800-557-6916 or emailing
[email protected].
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USFHP’s goal is to ensure that the comprehensive adolescent wellness examination provides opportunities for you to improve your patient’s, our member’s, health and to help initiate trusting relationships between patient and provider.
NEW MEMBER I.D. CARDS A new claims transaction system will be implemented for our Johns Hopkins US Family Health Plan (USFHP) in the near future. We are excited about this new, highly flexible claims system because it will allow us to better serve our provider community.
“At first, when I realized I had diabetes, I did not want to accept it,” Yvonne Baker, information receptionist, Guest Services, Johns Hopkins Hospital acknowledged. “And I didn’t do the things that I should have.” That was almost three years ago, before she began EHP’s care management program; before she discovered how EHP could help her control her condition.
In an effort to promote wellness visits among our adolescent population, we are holding a raffle. All adolescents who schedule and complete a wellness visit within a specified time frame will be entered into this raffle for the chance to win a $50 gift card.
Rebecca Cirri is a care manager at Johns Hopkins HealthCare in Glen Burnie, MD.
In conjunction with the new claims system, all USFHP members will receive a new member identification card with a new member number. Any claims, inquiries, or appeals for your USFHP patients, submitted on or after the implementation date, should be submitted with the new member number.
Please note that current member numbers start with U000000*01. New member numbers will be a random nine-digit number, such as 800000000. If you have additional questions regarding the claims system changes, please contact our Customer Service department at 410-424-428 or 800-808-7347.
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PRSRT STANDARD U.S. POSTAGE PAID PERMIT #273 ANNAPOLIS, MD JOHNS HOPKINS HEALTHCARE 6704 CURTIS COURT GLEN BURNIE, MD 21060
If you have questions regarding fraud, or suspected fraudulent activities involving a Priority Partners, Employer Health Programs (EHP) or Johns Hopkins US Family Health Plan (USFHP) member, provider or employee, please contact Corporate Compliance at 410-424-4996; or fax to 410-762-1527; or email
[email protected]. PP
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provider relations meet and greet The Provider Relations team at Johns Hopkins HealthCare (JHHC) is responsible for the overall management of the JHHC provider network. This dedicated group of professionals work both individually and collectively to educate providers on administrative policies and procedures; to communicate changes and updates for providers so they are able to effectively administer our plans; advocate on behalf of our providers to resolve any issues; initiate the credentialing process for new providers; and much more. Meet Nick Rebbert, a Provider Relations network manager. As a network manager, Nick is responsible for the maintenance and development of the provider network, specifically pertaining to non-Hopkins hospitals, ambulatory surgery centers (ASCs), skilled nursing facilities (SNFs), hospice providers, and urgent care facilities. Nick is also responsible for provider education and issue resolution for each of our product lines. If you need assistance from Nick, please contact him at:
[email protected] or call him at 410-689-1116. For additional information about the Provider Relations team, please visit our website Nick Rebbert at: www.hopkinsmedicine.org/johns_hopkins_healthcare/providers_physicians/
Fall 2016
Johns Hopkins Advantage MD
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FLU IMMUNIZATIONS Johns Hopkins Advantage MD and Advantage MD Plus members may receive flu vaccines at any participating provider’s office or participating pharmacy. In either instance, there is no in-network deductible, coinsurance, or copayment for the flu vaccine, which is covered once a year, either in the fall or winter.
IMPORTANT NOTICE: PRESCRIBER ENROLLMENT UPCOMING CODING SEMINARS
Effective February 1, 2017, per Centers for Medicare & Medicaid Services (CMS), Part D Prescribers must be enrolled in Medicare or have a valid opt-out affidavit on file with the applicable Medicare Administrative Contractor (MAC) to prescribe Part D drugs. For more information, visit the CMS Part D Prescriber Enrollment page at go.cms.gov/Prescriber Enrollment.
Accuracy and completeness of coding is of the utmost importance. In order to assist our providers toward improving coding accuracy, Johns Hopkins HealthCare (JHHC) will be hosting coding seminars. Primary care providers (PCPs) and specialists have been invited, as well as appropriate designee(s) who assist providers with coding. The final seminar for 2016 will provide additional tools and tactics that will help close gaps in care and optimize Medicare Advantage Hierarchical Conditioning Coding. This seminar is scheduled for Thursday, December 8. There will be a morning session from 9 a.m. to 12 p.m., and an afternoon session from 1 p.m. to 4 p.m. The seminar will be held at JHHC in Glen Burnie, MD. If you would like to attend, please register by contacting the Provider Relations Department at 888-895-4998 or by email at
[email protected]
ADVANTAGE MD ACCESS STANDARDS Service
Appointment Wait Time (not more than):
PCP Routine/Preventive Care
Thirty (30) calendar days
PCP Non-Urgent (Symptomatic)
Seven (7) calendar days
PCP Urgent Care
Immediate/Same Day
PCP Emergency Services
Immediate/Same Day
Specialist Routine
Thirty (30) calendar days
Specialist Non-Urgent (Symptomatic)
Seven (7) calendar days
Behavioral Health Routine Initial
Ten (10) business days
Behavioral Health Routine Follow-up
Thirty (30) calendar days
Behavioral Health Urgent
Forty-Eight (48) hours
Behavioral Health Emergency
Six (6) hours
Office Wait Time
Thirty (30) minutes
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MEDICAL AND BEHAVIORAL HEALTH Timely Utilization Management (UM) decisions are critical for the safety and quality of care provided to our membership. Decisions are made in a timely manner to accommodate the urgency of the member’s clinical situation, thereby minimizing disruption and/or delay to the provision of health care services. Timeliness standards for decision through notification for UM approvals and denials are outlined in Chapter 13 of the Medicare Managed Care Manual (www.cms.gov).
Standard Organization Determination The determination will be made as expeditiously as the member’s health condition requires, but no later than 14 calendar days after the date the organization receives the request.
Extended Timeframe The health plan may extend the timeframe to make a determination up to 14 additional calendar days if requested, and justified, to allow the member or organization time to provide additional information.
Expedited Organization Determination A written or oral request to expedite a determination may be made by a member or any provider, when they believe that waiting for a decision under the standard timeframe could place the member’s life, health, or ability to regain maximum function in serious jeopardy. If the health plan decides to expedite the request, the determination must be rendered expeditiously, but no later than 72 hours after receiving the request.
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PROVIDER MANUAL UPDATE The John Hopkins Advantage MD Provider Manual has a multitude of information regarding provider responsibilities, credentialing, benefits and services, pharmacy prescription benefits, care management, claims, quality improvement, compliance and much, much more. To access the Johns Hopkins Advantage MD Provider Manual, go to www.jhhc.com >Providers & Physicians >Resources and Guidelines, and click on Manuals.
FROM THE PHARMACY Pharmacy, formulary information, and resources for Johns Hopkins Advantage MD members are available to you on the Johns Hopkins HealthCare (JHHC) website at: www.hopkinsmedicine.org/johns_hopkins_healthcare/ providers_physicians/our_plans/medicare-advantage/pharmacy_formulary/index.html or call Customer Service at 877-293-5325.
ENROLLMENT INFORMATION The Medicare Annual Enrollment Period (AEP) is from October 15 to December 7, 2016. During this time, beneficiaries can join, change, or drop a Medicare Advantage plan or Medicare Part D prescription plan.
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The Advantage MD formulary will also be more robust for the 2017 plan year. Please refer to the winter edition of Hopkins Across the Board for additional details.
