UHA wants to help our members receive the best care possible. If you are a Primary Care Provider (PCP), you can help by doing your part to ensure that the correct members are assigned to you, the provider of their choosing. The member’s choice for provider assignment is encouraged. At any time, the member may call UHA’s Customer Care department to change their PCP. However, to facilitate accurate and convenient assignments, a provider can request a PCP change on behalf of the member.
UHA offers various ways for a PCP to verify a patient is correctly assigned. You can do this by:
Changes can be made by:
UHA Customer Care contact information is:
Preventative Medicine E/M Codes Added to the Telehealth Appendix
UHA is committed to continuing the coverage telehealth services for our members. We recognize that the coverage of telehealth is important to facilitate care during the COVID-19 outbreak and will continue to provide coverage in the future. UHA follows the Health Evidence Review Commission (HERC) guidelines for covered services and has added codes 99381 – 99387, 99391 – 99397, 99461 as covered when billed as telehealth. This is to encourage preventative care visits for our members and support the reporting of the CCO incentive metrics.
For your convenience, the telehealth code list is on our website. Please see the most recent telehealth appendix uploaded here: https://www.umpquahealth.com/claims/.
UHA Claims – Diagnosis Code Edits
UHA would like to provide a friendly reminder in regards to the importance of submitting claims with accurate diagnosis codes.
The Oregon Health Authority (OHA) turned the principal diagnosis code edit off in its systems several months ago as it was posting inaccurately. That has now been corrected and OHA is reviewing the possibility of turning this edit back on, effective 11/1/20. This will apply to both UHA and OHP fee-for service claims, billed with an invalid principal diagnosis code. These will be denied with adjustment reason code 16 and remark code MA63. To view a code list of invalid principal diagnosis codes considered invalid by OHA, please go here: https://data.oregon.gov/Health-Human-Services/Undefined-Diagnosis-Codes-Diagnosis-Code-Group-603/wi4n-ban3.
Also, claim denials with adjustment reason code 96 and remark code MA63, are due to the claim hitting UHA’s Prioritized List edit. This indicates the service was billed with a diagnosis that is below-the-line or non-covered based on OHA’s Prioritized List of Health Services. Please refer to the most current Prioritized List at: https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Prioritized-List.aspx for coverage information. If you have a question regarding a claim that processed with this edit, please reach out to the claims staff in UHA’s Customer Care department by calling 541-229-4842 or via email at UHAClaims@umpquahealth.com.
Prioritized List Updated 10/1/2020
The Prioritized List (PL) was updated October 1st with some interim changes before the annual update in January. The changes mostly consisted of additions to the diagnostic codes that are on covered lines. It is important to utilize the updated list for look-up of approved condition codes and treatment pairs, which is available at: https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Prioritized-List.aspx.
Top Ten Mistakes in Requesting Prior Authorizations
Once a year, we share the top ten list of most common mistakes in requesting Prior Authorizations (PA). This year, we’ll count down in October-November and then provide a preview of the new Prioritized List in December.
9. Don’t request an out of network specialty referral when services are already available in network. We support UHA providers and will deny unless there is a good reason.
8. Don’t request a PA without attaching documentation; this includes stating when a patient stopped smoking. We will utilize the information you provide to make the determination.
7. Check the PA grid on our website to learn what you can order without a PA; and for Retro requests >30 days, provide documentation with the claim and avoid the PA process
6. If you order an MRI of the spine, provide documentation that includes a history and neurologic exam to support the need for imaging (Diagnostic Guideline D4 & D11)
5. Migraine and tension headaches are clinical diagnoses; for other diagnoses, MRI may be warranted (Diagnostic Guideline D5).
MRIs are not therapeutic!
P&T Committee Update
UHA held our quarterly Pharmacy and Therapeutics (P&T) Committee meeting last week. This committee, composed of physicians and pharmacists, is responsible for determining what medications are covered on our formulary (list of covered medications) and coverage criteria, including prior authorization criteria. The P&T Committee has decided to make the following changes effective 11/1/2020:
|THERAPEUTIC CLASS||DRUG CLASS||DRUG NAME||STRENGTH||DOSE FORM||CHANGE||DESCRIPTION|
|ASTHMA AND COPD||GLUCOCORTICOIDS, ORALLY INHALED||ARNUITY ELLIPTA (FLUTICASONE FUROATE)||ALL STRENGTHS||INHALER||ADDED TO FORMULARY||COVERED UNDER PHARMACY BENEFIT WITH NO RESTRICTIONS.|
|ASTHMA AND COPD||ANTICHOLINERGICS, ORALLY INHALED LONG ACTING||SPIRIVA & SPIRIVA RESPIMAT (TIOTROPIUM BROMIDE)||ALL STRENGTHS||INHALER||CHANGED STEP THERAPY RESTRICTION||MUST FIRST TRY INCRUSE ELLIPTA (TUDORZA NO LONGER REQUIRED).|
|ASTHMA AND COPD||ANTICHOLINERGICS, ORALLY INHALED LONG ACTING||TUDORZA PRESSAIR (ACLIDINIUM BROMIDE)||400 MCG||INHALER||REMOVED FROM FORMULARY||INCRUSE ELLIPTA IS THE PREFERRED AGENT.|
|ASTHMA AND COPD||BETA-ADRENERGIC AND GLUCOCORTICOID COMBINATIONS||DULERA (MOMETASONE/FORMOTEROL)||50MCG-5MCG||INHALER||ADDED TO FORMULARY WITH STEP THERAPY RESTRICTION TO ALIGN WITH OTHER DULERA STRENGTHS||MUST FIRST TRY FLUTICASONE/SALMETEROL (GENERIC ADVAIR OR AIRDUO).|
|PAIN MANAGEMENT – ANALGESICS||ANALGESICS, NARCOTICS||OXYCODONE HCL ER||10 MG||ER TABLET||ADDED PRIOR AUTHORIZATION (PA) RESTRICTION||SEE PA GUIDELINES FOR DETAILS (RX005). CHANGE WAS MADE TO ALIGN WITH OTHER LONG-ACTING OPIOIDS.|
|PAIN MANAGEMENT – ANALGESICS||ANALGESICS, NARCOTICS||METHADONE HCL||5 MG, 10 MG||TABLET||ADDED PRIOR AUTHORIZATION (PA) RESTRICTION||SEE PA GUIDELINES FOR DETAILS (RX005). CHANGE WAS MADE TO ALIGN WITH OTHER STRENGTHS AND OTHER LONG-ACTING OPIOIDS.|
|PAIN MANAGEMENT – ANALGESICS||CALCITONIN GENE-RELATED PEPTIDE (CGRP) INHIBITORS||AIMOVIG (ERENUMAB-AOOE)||ALL STRENGTHS||AUTOINJECTOR||ADDED TO FORMULARY WITH PRIOR AUTHORIZATION (PA) RESTRICTION||SEE PA GUIDELINES FOR DETAILS (RX051).|
|PAIN MANAGEMENT – ANALGESICS||CALCITONIN GENE-RELATED PEPTIDE (CGRP) INHIBITORS||AJOVY (FREMANEZUMAB-VFRM)||ALL STRENGTHS||SYRINGE & AUTOINJECTOR||ADDED TO FORMULARY WITH PRIOR AUTHORIZATION (PA) RESTRICTION||SEE PA GUIDELINES FOR DETAILS (RX051).|
|PAIN MANAGEMENT – ANALGESICS||CALCITONIN GENE-RELATED PEPTIDE (CGRP) INHIBITORS||EMGALITY (GALCANEZUMAB-GNLM)||ALL STRENGTHS||PEN & SYRINGE||ADDED TO FORMULARY WITH PRIOR AUTHORIZATION (PA) RESTRICTION||SEE PA GUIDELINES FOR DETAILS (RX051).|
|PAIN MANAGEMENT – ANALGESICS||CALCITONIN GENE-RELATED PEPTIDE (CGRP) INHIBITORS||UBRELVY (UBROGEPANT)||ALL STRENGTHS||TABLET||ADDED TO FORMULARY WITH PRIOR AUTHORIZATION (PA) RESTRICTION||SEE PA GUIDELINES FOR DETAILS (RX051).|
|PAIN MANAGEMENT – ANALGESICS||CALCITONIN GENE-RELATED PEPTIDE (CGRP) INHIBITORS||VYEPTI (EPTINEZUMAB-JJMR)||ALL STRENGTHS||VIAL||ADDED TO FORMULARY WITH PRIOR AUTHORIZATION (PA) RESTRICTION||SEE PA GUIDELINES FOR DETAILS (RX051).|
|PAIN MANAGEMENT – ANALGESICS||CALCITONIN GENE-RELATED PEPTIDE (CGRP) INHIBITORS||NURTEC ODT (RIMEGEPANT SULFATE)||ALL STRENGTHS||ODT TABLET||ADDED TO FORMULARY WITH PRIOR AUTHORIZATION (PA) RESTRICTION||SEE PA GUIDELINES FOR DETAILS (RX051).|
|PAIN MANAGEMENT – ANALGESICS||ANTIMIGRAINE PREPARATIONS||ZOLMITRIPTAN ODT||5 MG||ODT TABLET||CHANGED QUANTITY LIMIT (QL) RESTRICTION||QL IS 9 TABLETS PER 30 DAYS.|
|PAIN MANAGEMENT – ANALGESICS||ANTIMIGRAINE PREPARATIONS||ZOLMITRIPTAN ODT||2.5 MG||ODT TABLET||CHANGED QUANTITY LIMIT (QL) RESTRICTION||QL IS 9 TABLETS PER 30 DAYS.|
|PAIN MANAGEMENT – ANALGESICS||ANTIMIGRAINE PREPARATIONS||ZOLMITRIPTAN
||2.5 MG||TABLET||CHANGED QUANTITY LIMIT (QL) RESTRICTION||QL IS 9 TABLETS PER 30 DAYS.|
|PAIN MANAGEMENT – ANALGESICS||ANTIMIGRAINE PREPARATIONS||ZOLMITRIPTAN
||5 MG||TABLET||CHANGED QUANTITY LIMIT (QL) RESTRICTION||QL IS 9 TABLETS PER 30 DAYS.|
|PAIN MANAGEMENT – ANALGESICS||ANTIMIGRAINE PREPARATIONS||REYVOW (LASMIDITAN SUCCINATE)||ALL STRENGTHS||TABLET||ADDED TO FORMULARY WITH PRIOR AUTHORIZATION (PA) AND QUANTITY LIMIT (QL) RESTRICTIONS||SEE PA GUIDELINES FOR DETAILS (RX023). QL IS 4 TABLETS PER 30 DAYS.|
|PAIN MANAGEMENT – ANALGESICS||ANTIMIGRAINE PREPARATIONS||SUMATRIPTAN SUCCINATE||6 MG/0.5ML||SYRINGE||ADDED TO FORMULARY WITH PRIOR AUTHORIZATION (PA) AND QUANTITY LIMIT (QL) RESTRICTIONS||SEE PA GUIDELINES FOR DETAILS (RX023). QL IS 4 TABLETS PER 30 DAYS.|
For the comprehensive list of medication coverage changes, formulary and prior authorization criteria, see the UHA Pharmacy Services webpage at https://www.umpquahealth.com/pharmacy-services/.
Douglas Public Health Network staff are working to address COVID-19 in Douglas County. Click http://douglaspublichealthnetwork.org/ for information on how to keep up with the latest local news related to coronavirus, and be sure to request their expanded daily report of COVID-19 related news to be sent to your inbox.
Given the continuation of the COVID-19 epidemic, it is even more important this year to ensure all of our patients receive Influenza Vaccine!
Suicide Prevention Training, sponsored by Adapt
QPR Stands for Question, Persuade, and Refer: 3 Simple steps anyone can learn to help save a life from suicide. People trained in QPR learn how to recognize the warning signs of a suicide crisis and how to question, persuade, and refer someone at risk to get the help they need.
In this QPR training you will learn to:
Friday, October 16th 2pm – 4pm Online Training
Register at https://qprsavealife.eventbrite.com
Questions – Adamj@compassoregon.org
REALD webinar series for CCOs and clinics
Sections 40-43 of House Bill 4212 (2020) require the OHA to adopt rules requiring healthcare providers to collect Race, Ethnicity, Language, and Disability (REALD) data for all COVID-19 encounters and report this data in accordance with Oregon’s disease reporting rules. REALD is an effort to increase and standardize race, ethnicity, language, and disability data collection across DHS and the OHA.
Phase 1 collection begins Oct. 1, 2020 for hospitals (except for licensed psychiatric hospitals), for healthcare providers within a health system, and for healthcare providers working in federally qualified health centers. Phase 2 begins March 1, 2021 for healthcare facilities and healthcare providers working in or with individuals in a congregate setting. Finally, all healthcare providers must start reporting information by October 2021. For more information, see the Oregon Health Authority’s House Bill 4212 Rulemaking and Implementation Fact Sheet.
The OHA Transformation Center and Division of Equity and Inclusion are hosting a webinar series focused on the use of REALD (race, ethnicity, language and disability) for CCOs and clinics. REALD is an effort to increase and standardize race, ethnicity, language and disability data collection across DHS and OHA. The webinar series will cover an introduction to REALD, impact on health equity work, strategies for asking REALD questions, and using REALD data to advance health equity. Presenter: Marjorie McGee (REALD Equity & Inclusion Policy Data Analyst)
An introduction to REALD
Strategies for asking REALD questions
Using REALD data to advance health equity
Phone option: +1-669-254-5252