Provider Newsletter May 2020
Practice Tactics
CIM Improvements
UHA has combined our E&M: Office Visit Services code group to include both new patient and established patient codes, 99201-99205 and 99211-99215. This means you only need to enter one of the codes from this range and the total quantity of visits requesting when entering a prior authorization.
CIM has updated the steps when entering a prior authorization (PA).
When selecting “Submit Pre-Authorization” or “Submit Referral”, you will be led through various pop-up windows to select the appropriate type of care: Pre-Authorization, Provider Enrollment, Appeal, or Grievance.
If selecting Pre-Authorization, you will be given the choice of entering a Medical, Behavioral Health or Pharmacy PA. The benefit of segmenting this workflow will be the improvement of standardization and accuracy as only the applicable options will be available for selection. For example, if selecting a Pharmacy PA, the only authorization types you will be allowed to choose are Injectable or Pharmacy Drugs.
Update on Member Appeals and Grievances
UHA processes member complaints as required by the Oregon Administrative Rules. We have procedures for both Member Appeals and Grievances. A member Appeal is a complaint related to a denial or limited authorization of a requested covered service. This includes a reduction, suspension or termination of a previously authorized service; a denial of payment for service; the failure of the Health Plan to act within timeframes; or a denial of request to obtain services outside of the Health Plan’s participating Provider panel. For all such examples, the Member will receive a written “Adverse Benefit Determination” letter from UHA with information of their right to Appeal the decision. If the Member asks you to help with this process, you should:
•Advise the Member to contact UHA in writing or by phone at 541-229-4842 to begin the appeal process.
•With written consent from the member, you can submit the appeal on behalf of the member.
•Keep the Member’s complaint confidential.
UHA will also investigate if the Member expresses any sort of complaint or dissatisfaction with you or to you about some aspect of their care. This Grievance is a complaint from a Member that is related to access, interaction with a provider or UHA, discrimination, billing, quality of care or services, and consumer rights. If the Member wants to pursue their complaint, they can do so by following the UHA Grievance procedure. If the complaint is something you can help with, please do not hesitate to address their concerns. For instance, if a Member complains about a long wait for an appointment, you can apologize for the wait and consider ways to remedy the situation. We encourage you to deal with Member complaints promptly and sensitively. In no event should you discourage a Member from making a complaint with UHA, but that does not mean that you cannot address a Member’s complaint and allow the Member to decide whether to follow up with UHA or not. If a Member does want to file a formal Grievance, you should:
- Advise the Member to contact UHA in writing or by phone at 541.229.4842.
- Be proactive by documenting the occurrence in details, using objective and professional comments.
- Provide UHA with a written response that addresses the issue and explain any action or resolution that occurred.
- Education your staff on health literacy, member rights, social determinants of health, empathy and compassion.
- For more information, please see your Provider Handbook for details and contact information.
Update on Claims Appeals Process by Providers
No printer, no problem! UHA has updated the Provider Request for Reconsideration and Claim Dispute form to include fillable fields enabling you to do a completely electronic clam appeal. With the new claims appeal process effective 4/1/2020 there are a few things to remember:
• A Provider Request for Reconsideration and Claim Dispute form will be required for all second level appeals, this can be found here: https://www.umpquahealth.com/wp-content/uploads/2020/04/claims-appeal-reconsideration-form-updated.pdf
Please note the Level II requirements on the form to avoid an invalid appeal submission
• The How to Upload Documents tutorial has been updated with clear guidelines and instructions for both Level I and Level II appeals, this can be found here : https://www.umpquahealth.com/wp-content/uploads/2020/04/how-to-upload-additional-documentation-pdf.pdf
• Electronic claim support through E-mail via claim in CIM. Change the autofill email to UHAClaims@umpquahealth.com and get claims support without having to call!
Keep an eye out for a few more updates rolling out in May including an updated How to Upload Documents tutorial and appeal guidance in the Provider Handbook. These changes are effective for appeals received after 4/1/2020, regardless of the date of service. Please visit our website at www.umpquahealth.com\claims\ and feel free to reach out with any questions to UHAClaims@umpquahealth.com or by phone 541-229-4812, option 2.
Clinical Corner
You asked, we answered: UHA pharmacy drug coverage changes are now posted online
The UHA formulary (list of covered drugs) and prior authorization (PA) guidelines are updated at least quarterly based on recommendations from the UHA Pharmacy and Therapeutics committee. This committee is composed of physicians and pharmacists from UHA and the community. At the request of some of our providers, we have added a document to the UHA pharmacy website that contains all updates made to the UHA formulary and PA guidelines since January 1, 2020. This document, along with our formulary and PA guidelines, will be updated quarterly and the current versions are posted on the UHA Pharmacy Services webpage: https://www.umpquahealth.com/pharmacy-services/.
UHA is seeking a Physician or other Provider from the community to fill a vacancy in our Pharmacy and Therapeutics Committee
The UHA Pharmacy and Therapeutics (P&T) Committee is a 6-member volunteer, advisory committee of physicians and pharmacists. The mission of the Committee is to encourage safe, effective, and innovative drug policies that promote high value medications for patients served by UHA. Among the key responsibilities, the Committee performs drug use review, determines which drugs and restrictions should be included on our formulary (list of covered drugs), and advises UHA on development and application of criteria and standards for coverage. P&T recommendations are based on evaluation of the available evidence on safety, efficacy and value of prescription drugs. The Committee meets quarterly for two hours and has an option for remote Webex participation. Committee participants are compensated for the time required to attend the meeting and review the materials prior to the meeting. To apply, please contact the Committee Chair, Robin Traver at rtraver@umpquahealth.com.
Updated Telehealth Appendix
With all of the uncertainty and changes that are happening during this time, UHA is doing their best to provide our panel with resources to answer some of the billing questions. UHA had previously released a telehealth appendix in the SPECIAL EDITION PROVIDER NEWSLETTER – CORONAVIRUS #3 to give some guidance on code coverage and billing requirements. Since this release, UHA has expanded the coverage of telehealth due to the COVID-19 outbreak. The Health Evidence Review Commission (HERC) guidelines have expanded the coverage of audio, video, telephonic, and online services between providers and patients. This includes evaluations, assessments, and consultation office visits. OHA has released an announcement regarding their coverage of telehealth services. For more information, visit their website at https://bit.ly/OHPTelehealthServices.
Please see the most recent telehealth appendix uploaded here: https://www.umpquahealth.com/claims/
UHA’s Language Access Plan Now Includes Information on Telehealth
UHA has expanded the coverage of telehealth due to the COVID-19 outbreak. The Health Evidence Review Commission (HERC) guidelines have expanded the coverage of audio, video, telephonic, and online services between providers and patients. This includes evaluations, assessments, and consultation office visits. OHA has released an announcement regarding their coverage of telehealth services. For more information, visit their website at https://bit.ly/OHPTelehealthServices.
Please see our updated Language Access Plan and UHA Translation Services Flyer on our website located at www.umpquahealth.com/providers/. There you can find information about our Telehealth services and instructions on how to use Linguava for all of your Telehealth, Phone, Video, and Onsite Interpretation needs.
On the Lookout
Douglas Public Health Network officials are working to address COVID-19 in Douglas County. Click here for information on how to keep up with the latest local news related to coronavirus.
CME for Thee
Free Online Tobacco Cessation Counseling Training to Address Higher COVID-19 Risk for Cigarette Smokers (with CME)
What: With cigarette smokers at higher risk for COVID-19, this short online course will improve your care team’s ability to help patients quit tobacco. The course focuses on Brief Tobacco Intervention and Motivational Interviewing techniques.
Who: All members of the care team committed to supporting their patients to quit tobacco.
When: The course is self-paced and takes approximately 45 minutes. The course can be started, paused and resumed later as needed.
CMEs: This training has been reviewed and is accepted for up to 1.0 prescribed credit from the American Academy of Family Physicians (AAFP). For other licensing boards that may not pre-approve continuing education credits (for example, the Board of Licensed Professional Counselors and Therapists), please submit the certificate of participation to your accrediting body.
Access the training: https://www.oregon.gov/oha/HPA/dsi-tc/Pages/tobacco-cessation.aspx
Contact: Anona Gund (anona.e.gund@dhsoha.state.or.us)
Audience: CCOs, clinics^.
TA for Clinics to Address the Increasing Prevalence of Unhealthy Alcohol & Opioid Use due to COVID-19
The OHA Transformation Center is partnering with the Oregon Rural Practice-based Research Network (ORPRN) to support clinic technical assistance related to SBIRT for unhealthy alcohol and drug use. Concerns about a rise in unhealthy alcohol and drug use concurrent with the physical distancing needed to suppress COVID-19 morbidity and mortality, amplifies the need for supportive efforts related to SBIRT and behavioral health integration. This collaborative project, ANTECEDENT, can provide primary care clinics with 12 months of tailored support to implement changes to address unhealthy alcohol use. Additionally, ORPRN is offering a complementary technical assistance opportunity regarding chronic pain management and opioid prescribing (aka PINPOINT). Clinics across Oregon are invited to participate in these free technical assistance opportunities to respond to ramifications COVID-19 may have on SBIRT workflows for alcohol use and opioid management. (See flyer: https://www.oregon.gov/oha/HPA/dsi-tc/Documents/ORPRN-SBIRT-Antecedent-Pinpoint.pdf).
Contact: Alissa Robbins (Alissa.Robbins@dhsoha.state.or.us) or contact the program directly at ANTECEDENT@ohsu.edu.
Audience: CCOs, clinics.
Oregon Traditional Health Worker integration and Deployment Webinar Series
This webinar occurs several times. Please register for the date and time that works best for you.
https://register.gotowebinar.com/rt/3896660818212131596
The Oregon Health Authority’s Office of Equity and inclusion in Partnership with the Traditional Health Worker Commission will be convening a statewide CCO 2.0 Traditional Health Worker Webinar Learning Series.
The purpose of these webinar series is to engage Coordinated Care organizations, Health System Providers, CCO’s THW Liaison, THW Workforce, Private Payers, community based organizations, Culturally Specific Organizations and key Stakeholders in peer-to-peer learning and networking opportunities to work on strategies to better integrate and utilize Traditional health workers, with the goal of addressing social determinants of health.
After registering, you will receive a confirmation email containing information about joining the webinar.
