1199SEIU PROVIDER
Connections
Your Key to the 1199SEIU Benefit Funds
Summer/Fall 2014
Message from the Executive
Director
Our 1199SEIU Benefit Funds’ strong network of participating providers ensures that our members receive the quality medical care they need. And we know that the best way to help you provide that care is by keeping you up to date on what is happening at our Benefit Funds. One major change is that effective September 1, 2014, our Home Health Aides who currently receive their care through EmblemHealth will now access their care through our Home Care Benefit Fund. See more information on this change on page 2. In this issue of Provider Connections, you will learn about important changes to our prescription drug and prior authorization programs, benefit changes for our National Benefit Fund Wage Class III and Greater New York Benefit Fund Eligibility Class III members and other updates on our Funds’ policies. It is important to note that not all changes apply to all 1199SEIU members.Your 1199SEIU patients are covered by three separate benefit funds – the National Benefit Fund, the Greater New York Benefit Fund and the Home Care Benefit Fund – and there are some differences between these plans. We strive to provide you with the most up-to-date information on your 1199SEIU patients’ benefit changes through this newsletter, and you can also stay current by calling our automated provider hotline at (888) 819-1199 or visiting our online Provider Portal at www.1199SEIUFunds.org/Providers. As always, we hope you find this newsletter useful. If you have any questions, your dedicated Provider Representative is available to help, or you can contact our Provider Relations Call Center at (646) 473-7160.
We know that the best way to help you provide quality medical care is by keeping you up to date on what is happening at our Benefit Funds.
Mitra Behroozi, Executive Director 1199SEIU Benefit and Pension Funds Your 1199SEIU patients belong to three different benefit funds: the National Benefit Fund, the Greater New York Benefit Fund and the Home Care Benefit Fund. Please make sure that you know which changes apply to which Fund.
1199SEIU Benefit Funds: Plan and Program News One Benefit Fund for All 1199SEIU Home Care Workers Begins September 1
1199SEIU Montefiore Coordinated Care Program Launched July 1
Effective September 1, 2014, the 1199SEIU Home Health Aide Benefit Fund will merge into the 1199SEIU National Benefit Fund for Home Care Employees (Home Care Benefit Fund), creating a single Fund for all 1199SEIU home care workers. That means many of your 1199SEIU patients who were previously enrolled in EmblemHealth’s HIP Health Plan of New York will now be enrolled in our Home Care Benefit Fund. All 1199SEIU home care workers will receive new Health Benefits ID cards, which you should ask for at their next appointment. The Home Care Benefit Fund offers your patients two plans to choose from, Plan A: the Member Choice Home Care Select Plan, or Plan B: the Panel Provider Plan, which ensures them quality healthcare from our broad network of participating providers.Your 1199SEIU patients who choose the Panel Provider Plan will have co-payments for some services, including $5 for doctor visits, $25 for emergency room visits, $3 for short-term generic medications and $6 for short-term preferred brandname drugs. Please refer to your patients’ Health Benefits ID card or call our Interactive Voice Response system (IVR) at (888) 819-1199 on the date of service for more information on eligibility for benefits. If you have any questions about the 1199SEIU Home Care Benefit Fund, please call our Provider Relations Call Center at (646) 473-7160 to speak with a representative.
On July 1, 2014, the 1199SEIU Montefiore Coordinated Care Program began coordinating care for nearly 16,000 1199SEIU members in the National Benefit Fund and the Greater New York Benefit Fund. 1199SEIU patients can work with a care management team – consisting of nurses, social workers, pharmacists and other healthcare professionals – to develop a personalized plan for managing a chronic condition, recovering from a serious illness, transitioning from a hospital stay to an aftercare setting or meeting any number of other health-related goals. The objective of this patient-centered approach is to help reduce hospital readmissions, eliminate unnecessary tests and referrals and support patients’ efforts to improve their overall health.
The Benefit Funds Enlist CareCore for Laboratory Management Program The 1199SEIU Benefit Funds have partnered with CareCore National, LLC, to provide prior authorization for certain outpatient molecular and genomic tests. Effective May 1, 2014, if your 1199SEIU patients require genetic tests, please request prior authorization by contacting CareCore either online at www.carecorenational.com or by phone at (844) 840-1199. The review program leverages CareCore’s experience in molecular and genetic testing to verify that the tests are medically necessary based on evidence-based criteria. All reviews are made within two days of CareCore receiving the necessary clinical information. However, if you require an urgent review, you may request one by calling (844) 840-1199. Effective July 1, 2014, CareCore will also review all claims submitted for outpatient molecular and genomic tests to verify that they adhere to the Benefit Funds’ clinical requirements and coding standards. For more information on the Laboratory Management Program, visit www.1199SEIUFunds.org/Providers or call (646) 473-7160.
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IOP/PHP Services Require Prior Authorization Providers must request prior authorization for their 1199SEIU patients to receive Intensive Outpatient (IOP) and Partial Hospitalization Program (PHP) services. To request prior authorization, call (646) 473-6868 and a representative from our Wellness and Member Assistance Program will collect the relevant clinical information and submit the request. The Funds will issue a decision in writing no later than 15 days after your submission. If you have any questions, please contact our Provider Relations Call Center at (646) 473-7160.
Hospital Indemnity Plan Takes Effect for 1199SEIU Patients in Wage Class III and Eligibility Class III Your 1199SEIU patients who receive National Benefit Fund Wage Class III benefits or Greater New York Benefit Fund Eligibility Class III benefits are no longer eligible for hospital coverage. These 1199SEIU members are part-time employees who, effective April 1, 2014, receive a limited hospital indemnity plan, dental and vision benefits, disability coverage and life insurance. To check which Fund your 1199SEIU patients belong to, as well as their Wage or Eligibility Class, please ask to see their Health Benefits ID card and call our Interactive Voice Response system (IVR) at (888) 819-1199 on the date of service. If you have any questions, call our Provider Relations Call Center at (646) 473-7160 and a representative will be happy to assist you.
Reminder: Behavioral Health Services for Greater New York Benefit Fund Patients Have a $5 Co-Pay If you provide behavioral health services to patients enrolled in the 1199SEIU Greater New York Benefit Fund, please remember that in accordance with the Mental Health Parity and Addiction Equity Act, effective January 1, 2014, co-payments for these services were reduced to $5 per visit. Be sure to check your 1199SEIU patients’ Health Benefits ID card to verify the Fund in which they are enrolled; the co-payment applies only to patients covered by the Greater New York Benefit Fund. There are no co-payments for mental or behavioral health visits for patients enrolled in the National Benefit Fund or the Home Care Benefit Fund.
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1199SEIU Benefit Funds: Claims Updates File Your Claims Electronically for Faster Payments We’ve made it easier for you to get paid quickly. With Emdeon, the Benefit Funds’ electronic payment and remittance reporting provider, you can have reimbursements deposited directly into your bank account at no cost to you. To enroll in Emdeon ePayment, call (866) 506-2830 or visit their website at www.emdeon.com/eft and fill out the enrollment form online.You can also fax your form to (615) 238-9615 or mail it to: Emdeon, P.O. Box 148850, Nashville, TN 37214 (Attention: Emdeon Electronic Payment Service Enrollment).You will continue to receive paper Explanation of Payment (EOP) statements for up to 45 days after enrollment, after which the Benefit Funds will generate a downloadable HIPAA-formatted Electronic Remittance Advice (ERA), or 835, file through your respective clearinghouse.You can also use Emdeon Payment Manager, an online application for Emdeon ePayment users.
Software Update: Claims Are Now Processed Using ClaimCheck 10.0 To maintain accurate and efficient claims processing, the Benefit Funds are now processing claims with the updated auditing software ClaimCheck 10.0. The system uses National Correct Coding Initiative (NCCI) guidelines to detect coding discrepancies, helping to improve the accuracy and turnaround time of provider claims. Please code your claims accordingly to avoid any unnecessary processing delays.
Preparations for ICD-10 Continue The 1199SEIU Benefit Funds continue to prepare for the transition to the ICD-10 system for diagnostic coding and inpatient hospital procedures, which the Centers for Medicare & Medicaid Services has postponed until October 1, 2015. Despite the delay, the National Uniform Claim Committee has made several revisions to the CMS-1500 4
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claim form to accommodate ICD-10, and the Benefit Funds will continue to accept either the modified version or the original form until further notice. We will post more information on how to submit claims using ICD-10 on our website at www.1199SEIUFunds.org/Providers as it becomes available.
“Like” Us on Facebook! Providing your 1199SEIU patients with information about what they can do to improve their health and well-being is just one of the ways we help complement your care, and the Benefit and Pension Funds’ Facebook page has proved to be a great tool. The more than 3,100 1199SEIU members who “Like” our page know they can go there to find news about their benefits, such as reminders to use the most up-to-date Preferred Drug List; details about health fairs, workshops and screenings; nutrition and fitness tips; and information on how to best access their healthcare and protect their health. To find out more, visit www.facebook.com/1199SEIUBenefitFunds, share it with your 1199SEIU patients and let us know what type of posts you think might be useful to them. And come back often – we’re sure you’ll find a lot to “Like”!
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1199SEIU Benefit Funds: Prescription Drug Coverage The Benefit Funds Do Not Cover Most Compounded Drugs The 1199SEIU Benefit Funds do not cover most compounded prescriptions. These drugs are generally for experimental or investigational use and they may contain ingredients that are not approved by the Food and Drug Administration. To help protect your 1199SEIU patients from potentially unsafe drugs and unnecessary out-of-pocket costs, please check our current Preferred Drug List at www.1199SEIUFunds.org/Providers before prescribing medications.
Four New Drug Classes Added to the Benefit Funds’ Preferred Drug List Our clinical staff regularly review the 1199SEIU Benefit Funds’ Preferred Drug List (PDL) to help ensure our members have access to the most cost-effective and clinically proven medications. Effective March 1, 2014, the Benefit Funds added four new drug classes to the PDL: • • • •
Epinephrine Auto-Injectors Erythroid Stimulants Insulin Therapy Irritable Bowel Syndrome
We have also made changes to five additional drug classes: • • • • •
Anticholinergic Agents (COPD) Injectable Hypoglycemic Agents (diabetes) Miscellaneous Pulmonary Agents Overactive Bladder Agents Ulcerative Colitis Agents
Before prescribing medications for your 1199SEIU patients, please check the most up-to-date PDL, effective July 1, at www.1199SEIUFunds.org/Providers. 6
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Twenty New Drugs Added to the Benefit Funds’ Specialty Care Pharmacy Accredo, the Benefit Funds’ specialty care pharmacy, has added 20 new drugs to its list of available medications, including drugs for breast cancer, colorectal cancer and cystic fibrosis. If you are prescribing any medication that requires refrigeration or other special handling, you must prescribe them through Accredo. In these cases, please call Accredo at (800) 987-4904 and provide them with the patient’s 1199SEIU Member ID number. The Accredo specialty pharmacist will arrange for the medication to be delivered directly to your patient or your office. Effective July 1, 2014, the new specialty medications are: • • • • • • • • • • • • • • • • • • • •
Adempas – pulmonary hypertension Alprolix – hemophilia B Bethkis* – cystic fibrosis Capecitabine – colorectal cancer, breast cancer Gazyva – chronic lymphocytic leukemia Granix – myelosuppressive chemotherapy Hetlioz – “non-24-hour” sleep-wake disorder in the blind Lupaneta – uterine disorder Moderiba* – hepatitis C Myalept – leptin deficiency Olysio* – hepatitis C Opsumit* – pulmonary arterial hypertension Oralair – hay fever Orenitram – pulmonary arterial hypertension ProThelial – mouth lesions Rixubis – hemophilia B Sovaldi* – hepatitis C Tobramycin inhalation (generic) – cystic fibrosis Tretten – clotting disorder Vimizim – enzyme disorder
*Medication requires prior authorization.
Deletions from the Benefit Funds’ Specialty Care Pharmacy Effective July 1, 2014, these two drugs are no longer included on our list of available specialty medications: • •
Novantrone – multiple sclerosis Orfadin – metabolic disorder
A full list of specialty care drugs is available at www.1199SEIUFunds.org/Providers. For additional information about the Benefit Funds’ prescription drug benefit plan, please call Express Scripts (formerly Medco) at (800) 211-1456 from 8:00 am to 6:00 pm, Monday through Friday.
New Prior Authorization Requirements for Prescription Drugs
Additional Specialty Drugs Requiring Prior Authorization As of April 1, 2014, the Benefit Funds have added four new medications to the list of specialty drugs that require prior authorization through Care Continuum’s Medical Benefit Management Specialty Drug Utilization Review Program: • • • •
Hetlioz – “non-24-hour” sleep-wake disorder in the blind Hyaluronic Acid Derivatives – osteoarthritis Orenitram – pulmonary arterial hypertension Otezla – psoriatic arthritis
Please contact Care Continuum through the ExpressPAth Portal at https://www.express-path.com for prior authorization of specialty drugs.You can also call Care Continuum at (877) 273-2122, or fax your request to (877) 814-4047. For an updated Medical Benefit Management Program Specialty Drug List, visit www.1199SEIUFunds.org/Providers.
As of June 3, 2014, the Benefit Funds have expanded the list of prescription drugs that require prior authorization through Express Scripts to include the medications below: • • • • •
Hyaluronic Acid Agents Leuprolide Long-Acting Agents (Lupron Depot/Eligard) Makena Osteoporosis IV Agents (Reclast/Boniva) Suboxone/Zubsolv
To request prior authorization for these drugs, contact the Express Scripts Prior Authorization Department at (800) 753-2851.
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