Provider Newsletter February 2020

Practice Tactics

Denials of PAs & Claims: the Appeal Process

UHA is required by the Oregon Health Authority (OHA) to notify members of denied prior authorizations (PA) and claims. These are mailed to the member and are attached in CIM to the PA and claim respectively. If you receive a call from a member regarding these denials, we advise you to first review the notification letter to determine the reason for the denial. (Some denials are only partial; the request may actually be approved, but not all elements or quantity.) We have several options, for both the provider and the member, to investigate and/or reprocess these requests when applicable. Please remember, providers are not able to bill the member for these denied services except under specific circumstances.

Members have the right to appeal these determinations. This can be done by filling out and returning the appeal form that is sent to them with the denial letter. Members who have difficulty completing the forms may ask for assistance from a friend or family member, or may call Member Services at (541) 229-4842 to have them fill out the Appeal form for the member to sign.

For claims, providers can submit a claims appeal, with supporting documentation, and appeal form to UHAClaimAppeal@PhTech.com through the claim in CIM, or mail it to:

PhTech, ATTN: UHA Claim Appeals
PO BOX 5308
Salem OR 97304

UHAs claims appeal process will be changing effective 2/1/2020 and the website implementation is finished. In addition, please see the provider handbook section 6 if there are questions, or email UHAclaims@umpquahealth.com with your questions.

For PA’s, providers can resubmit the request if there is supporting documentation that was not originally sub­mitted for a second review. We also offer providers the opportunity to discuss the determination with our Medical Director in a Peer-to-Peer phone meeting if it is believed to be an exception to rule. To schedule a meeting , please email PriorAuthorizations@umpquahealth.com or by calling Member Services at 541-229- 4842.

Intelligenz Moving to UHA, Rebranded as Umpqua Health Business Intelligence

Umpqua Health Alliance (UHA) has long partnered with Optima to provide the Inteligenz platform to help identify and communicate provider’s performance for the Coordinated Care Organization (CCO) Metrics Program.  The tool has allowed UHA to consistently perform in the top quartile of CCOs across the state for the Metrics Program.  However, UHA recently was informed by Optima that it no longer was going to offer the solution moving forward.  UHA was given the opportunity to integrate and operate the platform within its own infrastructure.

Effective February 1, the Inteligenz platform will now be maintained and supported by UHA.  Additionally, the platform will be rebranded as “Umpqua Health Business Intelligence.”  Since most providers and their staff have embedded the tool in their daily workflows, UHA recognizes the importance of maintaining the solution for the foreseeable future.  With the induction of CCO 2.0, and the Oregon Health Authority’s mandate of increase utilization of value-based payments, Umpqua Health Business Intelligence will be another valuable asset to drive and communicate performance to UHA’s network.

Please note that UHA does expect that there may be some down time during the first week of February.  Users can receive updates and access the new portal here.

If you have any question or concerns, please contact the following:

UHA Website Updates

As you may have noticed, we’ve made a few changes to the Providers section on our website. We hope these updates will make our site easier to navigate for providers and staff. If you have any questions or would like to speak to someone directly, our contacts page has a comprehensive list of UHA contacts.

Clinical Corner

Vision Coverage

We need to remind providers that the Oregon Health Plan has limitations on what services are covered for eye conditions.

  • Some medical conditions of the eye are covered for diagnosis and treatment. (Those below the line can be considered by exception to rule, based on comorbidity).
  • Vision services for refraction and visual acuity correction are limited to:
    • Children under 21 years of age
    • Pregnant women
    • Adults with a few medical conditions, including aphakia, keratoconus, or after cataract surgery

When you refer any OHP member other than those listed above for visual acuity evaluation, the ophthalmologist/optometrist will inform them of their financial liability.  Informing the member of this ahead of time will avoid a lot of confusion/frustration!

Smoking Cessation Before Surgical Procedures

Guideline A4 requires cessation of tobacco smoking 4 weeks prior to elective surgery/invasive procedures.  Exceptions include surgery for cancer or diagnostic reasons.  (Some surgeries, such as spinal fusion or bariatric surgery require a stricter criteria of cessation of all tobacco and nicotine for 6 months.)   This places a greater emphasis on accuracy of documentation in the clinical record.  If someone is a “former smoker” there should be an indication of the duration of the cessation.  Short time intervals might lead to a request for urine screening to verify status.  No documentation of smoking status will yield the same request.   The best test to order is a urinary cotinine with an anabasine test reflex order if cotinine positive.

On the Lookout

2019 Novel Coronavirus

On December 31, 2019, the WHO China Country Office was informed of a possible outbreak of pneumonia of unknown etiology in Wuhan City, China. By January 3, 2020, a total of 44 cases were identified. On January 7, 2020, the agent was identified as a novel coronavirus (2019-nCov). As of February 5, 2020 there were over 24,000 cases and 491 deaths in 25 countries worldwide, the vast majority of which were in mainland China. Only one fatality has occurred outside of China.

Since January 21st, there have been 260 people under investigation for novel coronavirus in the United States. As of February 5th, twelve have tested positive with 76 specimens awaiting testing. No cases have been reported in Oregon.  While the exact nature of the illness associated with this novel coronavirus is still unknown, reported illness from confirmed infections have ranged from little to no symptoms to severe and potentially fatal illness. The current data suggest that, with a mortality rate of approximately 2%, 2019-nCov is twice as infectious and 20 times more fatal than seasonal influenza with incubation period of 2 to 14 days.

Fortunately, infection risk is directly related to exposure risk. This means that for the general public unlikely to be exposed, the immediate health risk is considered low at this time. Additionally, nationwide measures have been enacted to reduce the risk of spread into the United States. However, if this coronavirus were to gain traction within the U.S., it’s important for providers to be prepared.

If you have a patient visit your clinic with fever or symptoms of lower respiratory illness (cough, shortness of breath) AND travel to China or close contact with a confirmed case of 2019-nCoV illness in the 14 days since first onset of symptoms, place a facemask  on the patient (recommended for all patients with fever and respiratory symptoms) and isolate them in a private room, preferably negative pressure.  All suspected patients should be placed under airborne and contact precautions, and all healthcare workers in contact with the patient should wear appropriate personal protective equipment (PPE), including eye protection. Once you assess clinical status and confirm fever and/or symptoms of upper respiratory illness, contact Douglas Public Health Network immediately at 541-677-5814. A flowchart for the identification and assessment of patients can be found here: CDC Flowchart.

Resources, recommendations, and situation updates can be found at the following websites, all of which are updated regularly:

OHA (local): www.healthoregon.gov/coronavirus; Fact Sheet
CDC (US): https://www.cdc.gov/coronavirus/2019-ncov/index.html
WHO (global): https://www.who.int/emergencies/diseases/novel-coronavirus-2019

If you have any additional questions regarding the 2019-nCov and how to handle potential cases, please contact DPHN’s Communicable Disease Officer at 541-677-5814.

National Condom Month

February is National Condom Month.  According to the CDC, when used correctly condoms are 98% effective at preventing pregnancy. Condoms are also the only contraceptive method that also protect against sexually transmitted infections (STIs).  Every year, approximately 20 million cases of STIs occur in the United States, resulting in almost $16 billion in health costs; yet, according to the CDC, only 1 in 3 sex acts among single persons include condom use.

While most effective at preventing STIs spread by bodily fluids, such as chlamydia, gonorrhea, and HIV, condoms can also significantly reduce the risk of diseases spread by skin-to-skin contact like herpes and HPV—as long as the sores caused by these infections are covered by the condom. As with pregnancy prevention, condom usage is most effective when condoms are used properly.

Douglas Public Health Network provides condoms, lube, and usage instructions at no charge. If you are interested in supplies for your clinic, please contact DPHN’s Communicable Disease officer at 541-677-5814.

Quit Resources

We are now one month into the new year, and one month into New Year’s resolutions. New Year’s Resolutions often involve self-improvement and a focus on improved health and wellbeing. For those who are trying to quit smoking, there are several resources available.

The Oregon Quit Line is a free and available 24/7 at 1-800-QUIT-NOW and quitnow.net/Oregon. Resources are available for all Oregonians of any age wanting to quit using any type of tobacco or nicotine product.

Douglas County youth and young adults, between the ages of 13 and 24, who are interested in quitting vaping can enroll in a FREE, text-based cessation program from the Truth Initiative called This Is Quitting. Messages are tailored to participant age and product usage and provide support, tips, and advice to help users quit. Those not yet ready to quit can also enroll and will receive messages designed to help build the confidence and skills needed to take that next step. To enroll, patients need only text “VAPEFREEDC” to 88709.

This Is Quitting is available in Douglas County as part of collaboration between DPHN, CHI Mercy Health, and Blue Zones Project-Umpqua.

Palm cards and flyers have been distributed to schools, youth organizations, and clinics across the county. If your clinic hasn’t received materials and would like them or needs more, please contact DPHN’s Tobacco Prevention and Education Program Coordinator at 541-677-5825.

Information in this section is provided by Douglas Public Health Network. If you have any questions about the content, please contact the DPHN office at (541) 440-3571.

CME for Thee

Mercy Medical Center Grand Rounds: Monday, March 2 @ 12:15 PM

Boot Camp for Physicians:
How to Navigate the System for your Oregon Medicaid Patients

  • Identify the unique characteristics of the Oregon Health Plan.
  • Learn how to access the Prioritized List and apply it to my practice.
  • Review the common conditions that are funded/not funded by OHP.
  • Gain tips on submitting Prior Authorizations to Umpqua Health Alliance.
  • View the flier for more information.

From the OHA Transformation Center:

1. HbA1c Diabetes Incentive Metric Support – Webinars

Join the Transformation Center for three webinars focused on the HbA1c incentive metric. These webinars will be presented by Dr. Andrew Ahmann, director of the Harold Schnitzer Diabetes Health Center and recipient of the 2018 Outstanding Physician Clinician in Diabetes Award from the American Diabetes Association.

  • *NEW WEBINAR* Tailoring Nutrition Programming to Fit Different Communities and Populations. 1/30, noon-1 p.m. Register here
    • Audience: CCO staff working on quality improvement, diabetes care and patient nutrition.
  • Working with pharmacists on a diabetes care team. 2/3, noon-1 p.m. Register here
    • Audience: Primary care physicians, specialty physicians, physician assistants, nurse practitioners, pharmacists.
    • Available for CMEs. See attached flyer for details.
  • Patient education and engagement in diabetes care. 2/28, noon-1 p.m. Register here

2. Kindergarten Readiness Technical Assistance

The Transformation Center will be providing technical assistance for the two incentive measures designed to support kindergarten readiness: 1) Well-child visits for 3–6-year-olds; and 2) Preventive dental visits for ages 1–5. Additional webinars will be announced soon.

  • Well-child visit peer sharing: EOCCO Child Wellness Campaign, IHN Gap Reporting/Closure, and PacificSource Provider Engagement. 2/5 11 a.m.-noon

Eastern Oregon Coordinated Care Organization quality improvement staff will present their new hybrid Child Wellness Campaign. This member outreach uses multiple channels to impact several CCO incentive measures – including well-child visits, preventive dental services, and adolescents and childhood immunizations. Presenters will discuss designing a project plan to address multiple measures, creating audience-appropriate content, and working with external partners to broaden the scope of incentive measure improvement projects.

InterCommunity Health Network CCO staff will review IHN’s process for building and verifying reporting on measure data and how IHN shares that data back to providers, collaborates around accuracy of findings, and gains insights into improved reporting. PacificSource staff will discuss their strategy for engaging and working with community providers including monthly meetings, community workshops on pertinent topics and quarterly all clinic meetings.

3. Behavioral Health Technical Assistance Webinar Series

CCO staff and Oregon Health Plan providers are invited to participate in technical assistance for behavioral health requirements in the 2020 CCO contracts. This webinar series is hosted by the OHA Transformation Center and presented by OHA’s Child and Family Behavioral Health Team. See attached PDF for full details.

Contact: Summer Boslaugh (summer.h.boslaugh@dhsoha.state.or.us, 503-753-9688)
Audience: CCO behavioral health staff, behavioral health providers, primary care providers and other service providers, depending on webinar topic.

4. Technical Assistance for Clinics: Alcohol & Opioid Management

The OHA Transformation Center is partnering with the Oregon Rural-based Practice Research Network (ORPRN) for the screening, brief intervention and referral to treatment (SBIRT) CCO incentive metric. This technical assistance, designed for clinics, is a 3-year study funded through the Agency for Healthcare Quality and Research. The project, referred to as ANTECEDENT (pArtNership To Enhance alCohol scrEening, treatment anD intervENTion) is designed to address unhealthy alcohol use in primary care. Additionally, the PINPOINT Collaborative is a separate technical assistance opportunity supporting clinics to address chronic pain management and opioid prescribing. Clinics are invited to participate in free technical assistance (see flier).

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