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HFMA PAYOR PANEL NOVEMBER 15, 2017
PRESENTED BY
NICKY COONEY AND NAT KONGTAHWORN Network Engagement Business Partners 1
OPERATIONS MEDICAL
OPERATIONS
GENERAL INFORMATION WORKING WITH WELLMARK CONTACTS
2
NEW STANDARD WAIVER TEMPLATE FORM •
•
Periodically receive inquiries as to what is necessary to include a the waiver form •
The Claims Filing Guide details the required elements of a valid waiver
•
Led to development of standard waiver form
The form will be accessible in two ways: •
Interactive link in the Claims Filing Provider Guide
•
Miscellaneous Forms Quick Link on the Wellmark Provider Portal
•
The member and a provider representative must sign the form
•
The form includes verbiage about the member explanation of benefits
•
Optional template form for provider use
3
TIME SAVING IMPROVEMENT FOR CLAIMS FILING • Prior to August 1, 2017
• A claim with an unlisted/not otherwise classified (NOC) procedure code was denied X922 - not meeting criteria • Providers asked to include a medical record/report of the services when resubmitting the claim on paper
• Effective August 1, 2017
• Providers will only see the X922 denial code when an unlisted/NOC procedure code is submitted without the description • Providers can resubmit the claim electronically because the medical record or report is not needed
• Please refer to the Claims Filing Section of the Provider Guide- Chapter 17 for additional direction
4
EXTENDED PROVIDER SERVICE HOURS •
Effective October 2nd, 2017, Wellmark's Provider Service phone lines hours were extended
•
Hours are 8:30 a.m. – 5 p.m. CDT, for regular, BlueCard®, and Federal Employee Program (FEP) business •
You may reach our Provider Service representatives at 1-800-362-2218
•
FEP Provider Service representatives may be reached at 1-800-532-1537
5
ROSTER BILLING: FLU SHOTS •
As a reminder, Wellmark does not accept roster billing of Flu Shots
6
OPERATIONS MEDICAL
MEDICAL
GENERAL INFORMATION WORKING WITH WELLMARK CONTACTS
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NEW CRITERIA •
2017 InterQual® criteria was implemented on October 13, 2017: •
Important to review WINS messages
•
Revisions posted prior to implementation
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PRIOR AUTHORIZATION UPDATES •
MRI Pelvis: •
Effective for dates of services November 9th, 2017
•
InterQual® criteria used to determine medical necessity
9
SLEEP STUDIES •
Wellmark reviewing options for Facility Based Sleep Studies •
Currently review claims post service
•
Exploring implementation of Prior Authorization for Facility-Based Sleep Studies −
•
Change gives both provider and member the opportunity to know medical necessity PRIOR to the services being performed in a facility instead of in the home
As a reminder we do NOT review Home Sleep Studies
10
LOWER-COST GENERIC ALTERNATIVE TO ADVAIR •
•
Fluticasone/salmeterol (the authorized generic for AirDuoTM RespiClick®), a lower cost alternative for Advair •
Now available on Tier 1 of the Wellmark Drug List
•
This medication could result in substantially lower out-of-pocket costs for members
Although Teva Pharmaceutical Industries’ authorized generic is not directly substitutable with GSK’s Advair •
•
Up to 81% less expensive
The two asthma products contain the same active ingredients but differ in several important ways: •
They come in different strengths and devices
•
AirDuo lacks Advair’s approval in chronic obstructive pulmonary disease and is only approved for ages 12 and up
11
OPERATIONS MEDICAL GENERAL INFORMATION
GENERAL INFORMATION
WORKING WITH WELLMARK CONTACTS
12
STATE OF IOWA HEALTH PLANS •
Effective January 1, 2018, the State of Iowa will offer employees a new health plan (still through Wellmark)
•
State of Iowa is marketing these plans to employees as Iowa Choice and National Choice
•
There are no network changes • Iowa Choice uses the Blue Access Network •
National Choice uses the Alliance Select Network
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HY-VEE HIGH PERFORMANCE NETWORK PLAN •
In 2018 Wellmark client Hy-Vee will pilot a high performance network benefit design offered to a subset of Hy-Vee employees
•
In this benefit design, employees are incented for office-based services only to use two high performance ACO providers: •
McFarland Clinic
•
The Iowa Clinic
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Patient has lower copay when visiting Tier 1 providers (PCPs and Specialists)
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Higher copay for Tier 2 providers (PCPs and Specialists) – still considered in-network
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OPERATIONS MEDICAL GENERAL INFORMATION WORKING WITH WELLMARK
WORKING WITH WELLMARK
CONTACTS
15
UPCOMING EDUCATION •
Creating a Safe and Welcoming Environment •
November 8, 2017 noon – 1:00 p.m. CDT
• 2018 Product Overview
• December 13, 2017 noon – 1:00 p.m. CDT
• Update to Wellmark’s Claims Processing System • January 10, 2018 noon – 1:00 p.m. CDT
16
WELLMARK INFORMATION NOTIFICATION SYSTEMS (WINS) • Real time notification • Messaging focuses on: •
Wellmark policy changes that impact you and your business and/or business processes – including Medical Policy Updates
•
Issues that impact how Wellmark does business with the provider community
• How Do Providers Sign-up for WINS? •
Log into Wellmark.com secure portal
•
Click on Wellmark Information Notification System (WINS) under Quick Links
•
Complete basic demographic information
•
Select message categories in which you are interested
17
OPERATIONS MEDICAL
CONTACTS
GENERAL INFORMATION WORKING WITH WELLMARK CONTACTS
18
NETWORK ENGAGEMENT TERRITORIES
19
THANK YOU!
Wellmark Blue Cross and Blue Shield of Iowa is an Independent Licensee of the Blue Cross and Blue Shield Association. Confidential and Proprietary – Wellmark Blue Cross and Blue Shield.
