Summer 2021 pt.1
Provider Partners - Report and Validate Your Data With HPSJ Provider Directory regulatory standards are in place to ensure Medi-Cal health plans publish and maintain accurate directories. As part of the mandated regulations, Health Plan of San Joaquin (HPSJ) must validate provider information at least every six months and update the provider directory as often as necessary to ensure accurate information is available for our members. We are requesting your cooperation in this effort by verifying the provider data associated with your clinic organization. Please use the HPSJ Roster Template when reporting data reporting during the required validation process. The HPSJ Roster Template is available on our website, visit www.hpsj.com/forms-documents to download the document now.
Forms to use: ▪
Attestation Form (1st Tab – required)
▪
HPSJ Roster Template (select the “Tab” that suits your provider type)
Enter all provider information requested and promptly email the completed roster to HPSJ within 30 days from the date of this letter. Email your documentation to: providernetworks.verification@hpsj.com
Your provider/clinic information may be temporarily removed from our directory if HPSJ does not receive the requested data updates in a timely manner to verify the accuracy of the information we have in our database (per Senate Bill 137). Failure to verify your information may also result in a delay of payment or reimbursement of claim(s). Once the provider data is validated and corrected, HPSJ will then restore and display your provider information in the directory.
We look forward to collaborating with you on this effort. If you have questions or need assistance, please call our Provider Services Department at (209) 942-6340.
In this issue:
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Provider Satisfaction Survey Results
3
2021 Timely Access Standards
4
Regulatory Requirement Reminders
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Authorized COVID-19 Vaccinator Info
2020 Satisfaction Scores are In! The results of the Provider Satisfaction Survey, conducted in the Fall of 2020, are in! The Provider Satisfaction Survey targets providers to measure their satisfaction with Health Plan of San Joaquin. Information obtained from these surveys allows the health plan to measure how well we are meeting the contracted providers’ expectations and needs.
The composite areas that we focus on include the following: ▪ Overall Satisfaction ▪ Network/ Coordination of Care ▪ All other Plans (Comparative Rating) ▪ Pharmacy
▪ Utilization and Quality management ▪ Health Plan Call Center Service Staff ▪ Provider Relations
Changes from last year
TRENDING
Questions that increased significantly from 2019 Access to Case/Care Managers from this health plan Quality of specialists in this plan’s provider network Consistency of the formulary over time Extent to which formulary reflects current standards of care Variety of branded drugs on the formulary Ease of prescribing your preferred medications within formulary guidelines Availability of comparable drugs to substitute those not included in the formulary
Net Satisfaction Score:
77
Net Loyalty Score:
77
2020 Summary Rate Score
2019 SPH/Vendor Medicaid Book of Business Percentile
Willingness to Recommend
95%
93rd
All Other Plans (Comparative Rating)
58%
97th
Overall satisfaction
81%
94th
Utilization and Quality Management
54%
96th
Network / Coordination of Care
42%
94th
Pharmacy
40%
98th
Health Plan Call Center Service Staff
48%
93rd
Provider Relations
48%
91st
Measure Name (% Yes)
(% Well or Somewhat above average) (% Completely or Somewhat Satisfied)
(% Well or Somewhat abouve average) (% Well or Somewhat abouve average) (% Well or Somewhat abouve average) (% Well or Somewhat abouve average) (% Well or Somewhat abouve average)
We are pleased with the results and upward trends and are working towards improved scores for 2021.
Updated Clinical Practice Guidelines Health Plan of San Joaquin (HPSJ) offers education and training tools to help our provider partners connect with our members and achieve best practice status. Clinical Practice Guidelines are about defined tasks or functions in clinical practice, such as desirable diagnostic tests, the optimal treatment regimen for a specific diagnosis, and links to resources. The guidelines, with best practices based on latest clinical evidence, have been reviewed by Health Plan of San Joaquin’s Medical Director and are posted on the HPSJ website at www.hpsj.com/clinical-practice guidelines. Additions include several new practice areas and more links to resources!
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Getting Patients in On Time Provider partners, please review, print, and post the following Timely Access Standards for those of your staff who schedule appointments for HPSJ members. Access standards are established by both the Department of Health Care Services (DHCS) and the Department of Managed Health Care (DMHC). In-office wait times for scheduled appointments are set and monitored by managed care plans. HPSJ members have the right to appointments within the following time frames:
Appointment Access Standards for Medi-Cal
Types of Services
Standard
Access to non-urgent appointments or primary care – regular and routine care (with a PCP)
Within 10 business days of request
Access to non-urgent appointments for mental health (non-physician)
Within 10 business days of request
Access to urgent care services that do not require prior authorization
Wait time not to exceed 48 hours of request
Access to urgent care (specialist and other) services that require prior authorization
Wait time not to exceed 96 hours of request
Access to non-urgent appointments with a specialist
Within 15 business days of request
Access to after-hours care (with a PPC)
Ability to contact on-call physician after hours within 30 minutes for urgent issues
Access to preventive health services within 30 business Access to preventive health services within 30 business days of request days of request Non-urgent appointments for ancillary services for the diagnosis or treatment of injury
Within 15 business days of request
In-office wait time for scheduled appointments (PCP)
Not to exceed 45 minutes
In-office wait time for scheduled appointments (specialist)
Not to exceed 60 minutes
If you have questions, contact our Provider Services Department at 209.942.6340. Per DMHC, non-physician mental health providers include counseling professionals, substance abuse professionals, and qualified autism service providers. Access the Timely Access to Care Fact Sheet by visiting the following URL: https://dmhc.ca.gov/Portals/0/Docs/DO/TAC_accessible.pdf
Join our celebration!
Access our 25-year timeline, throwback pictures of staff and events, and sign our guestbook!
Visit our web page at www.hpsj.com/25years
"To highlight pioneering efforts by HPSJ to enhance the local health care landscape, we proudly share with you our newest Community Report. As HPSJ looks to the future, we remain focused on serving our members and partnering to leverage regional resources to meet the health care needs of the San Joaquin Valley." - Michael Schrader, CEO
Read our Community Report http://tiny.cc/1cz2uz
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Annual Training Approaching Fraud, Waste & Abuse
HPSJ is committed to protecting members, our network of providers, and public interests by preventing, detecting, investigating, correcting, and reporting Fraud, Waste, and Abuse (FWA).
Cultural Competency
Health Plan of San Joaquin’s provider network and delegated entities are required to complete annual Cultural Competency training. The training is mandated by California’s Department of Health Care Services (DHCS) and the federal Centers for Medicare and Medicaid Services (CMS) to ensure providers and delegated entities are meeting the unique and diverse needs of all members. As part of new federal requirements, Cultural Competency training will be noted in the Provider Directory. To help you become more culturally and linguistically competent in providing care to HPSJ patients, HPSJ has adopted policies and procedures that are consistent with the National Standards (i.e., DHCS and California’s Department of Managed Health Care) for Culturally and Linguistically Appropriate Services (CLAS). These aim to ensure that HPSJ members receive:
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▪
Equal and respectful care in a manner compatible with their cultural health beliefs and practices
▪
Preferred language at every medical and non-medical encounter
Under legal requirements overseen by the federal Centers for Medicare & Medicaid Services (CMS), 42 C.F.R. §422.503 and 42 C.F.R. §423.504, you are required to either complete the FWA training offered on the HPSJ website and send HPSJ a signed attestation, or attest that you have completed another, acceptable FWA training.
Mark Your Calendar
Annual training will be launched end of summer/early fall 2021. HPSJ will provide more information and training resources for you in our upcoming provider newsletters in which you will:
1 2 3
Attest to receipt of training materials
Confirm you have completed review of training materials Acknowledge you have taken part in the Cultural Competency training and FWA training
As always, we appreciate your partnership, including the timely completion of training in the fundamentals of health care.
Cancer Screening Age Recommendation Drops The U.S. Preventive Services Task Force (USPSTF) has updated their 2016 recommendation on screening for colorectal cancer.
Recommendation Summary
The current recommendation, while continuing to recommend screening in adults aged 50 to 75 years (A recommendation), now recommends offering screening starting at age 45 years (B recommendation). As it did in 2016, the USPSTF continues to conclude that screening in adults aged 76 to 85 years should be an individual decision (C recommendation) and screening should be discontinued after age 85 years.
Population
Recommendation
Adults aged 50 to 75 years
The USPSTF recommends screening for colorectal cancer in all adults aged 50 to 75 years. See the "Practice Considerations" section and Table 1 for details about screening strategies.
Adults aged 45 to 49 years
The USPSTF recommends screening for colorectal cancer in adults aged 45 to 49 years.
Adults aged 75 to 85 years
The USPSTF recommends that clinicians selectively offer screening for colorectal cancer in adults aged 76 to 85 years. Evidence indicates that the net benefit of screening all persons in this age group is small. In determining whether this service is appropriate in individual cases, patients and clinicians should consider the patient's overall health, prior screening history, and preferences.
See the "Practice Considerations" section and Table 1 for details about screening strategies.
Grade
A B C
To view the recommendation and the evidence on which it is based, please visit the following URL: https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/colorectal-cancer-screening. Health Plan of San Joaquin staff are here to assist provider partners with the processing of these new claims.
Did You Get the Update? Provider Alerts are sent via fax to provider partner offices to communicate important regulatory updates and other helpful information and resources. Have you missed any of these important alerts? » » » »
Grievance Process Update Update on Value Bases Payment (VBP) Program COVID-19 Vaccine Administration Info Formulary Updates
Stay up-to-date with HPSJ and access past Provider Alerts at www.hpsj.com/alerts. Utilize the search function to find exactly what you're looking for!
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FWA Detection and Prevention is Key As a participating provider in the managed care program, recognizing the importance of prevention and detection of Fraud, Waste and Abuse (FWA) is a privilege and should not be taken lightly. There are key controls you can put in place in order to effectively detect and stop FWA in its tracks: 1. Conducting consistent assessments and audits of your operations to guard against FWA. 2. Make sure you have strong internal controls in place to ensure claims are submitted and payments are made properly. 3. Educate your staff on how to recognize incidences of suspected FWA and how to report it. 4. When in doubt, reach out to your Compliance and or Ethics team for guidance. This information can help you recognize possible noncompliance in your day-to-day operations so you can take proper action.
These are just a few small steps that will make a big difference in the fight against FWA. Click on the link to the right to read some of the latest announcements from the Department of Justice on recent investigated and prosecuted cases of fraud.
www.justice.gov/opa/pr/doj-announcescoordinated-law-enforcement-action-combathealth-care-fraud-related-covid-19
Payment Portal Switch-Over
Providers should be pleased with the new payment system coming soon! We have already begun the transition to this improved Payment Portal. We will be sending information to ensure a smooth transition for your electronic payments – or help you to transition away from paper to take full advantage of this new system. For now, we are asking the following:
TIME IS
RUNNING
OUT!
Please provide the email address of the person at your practice who is authorized to make decisions about claims, payments, and bank account information at www.hpsj.com/paycontact. This is time-sensitive so we ask that you provide this information as soon as possible. The new portal will be available to all HPSJ Providers, with these perks and advantages:
• Online storage for 10 years of Remittance Advice and Capitation documents! • More choices on how to receive payments, including electronic transfers to your bank account! • Streamlined search functions • 24/7 support! Questions? Please visit www.hpsj.com/pay, or call the HPSJ Provider Services Team at (209) 942-6320.
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Keeping HPSJ Members Safe During Fire Season With California facing drought conditions and a more year-round fire season, Health Plan of San Joaquin (HPSJ) now offers members detailed information and support at www.hpsj.com/stay-safe-during-fire-season. To help health care providers be ready for fire, smoke and ash emergencies, as well as power outages, HPSJ points to the Centers for Disease Control and Prevention where CDC offers great tools to help serve your patients. Find the CDC tool kit at www.hpsj.com/providers. HPSJ also asks members to KNOW THEIR COLORS when it comes to air quality and California’s fire season. The EPA’s AirNow site has valuable information on how to stay healthy and safe, at www.airnow.gov. Their free, colorful AirNow app, available at the Apple App Store or the Google Play Store, has hyper-local air quality updates so everyone can track the air quality in their area. HPSJ has helpful air quality information for members on our website, www.hpsj.com/stay-safe-during-fire-season. A Spanish version is posted at http://miembros.hpsj.com/seguridad-durante-incendios-y-cortes-electricos
Air Quality Index Air Quality Index Levels of Health Concerns Good
Numerical Value 0 to 50
Meaning Air quality is satisfactory, and air pollution poses little or no risk.
Moderate
51 to 100
Air quality is acceptable. However, there may be a risk for some people, particularly those who are unusually sensitive to air pollution.
Unhealthy for Sensitive Groups
101 to 150
Members of sensitive groups may experience health effects. The general public is less likely to be affected.
Unhealthy
151 to 200
Some members of the general public may experience health effects; members of sensitive groups may experience more serious health effects.
Very Unhealthy
201 to 300
Health alert: The risk of health effects is increased for everyone.
Hazardous
301 and higher
Health warning of emergency conditions: everyone is more likely to be affected.
COVID-19 Myth Busters Q&A's The HPSJ Myth Busters help answer COVID-19 questions based on public health guidance. You can access the Myth Busters at www.hpsj.com/coronavirus, and the Spanish version at http://miembros.hpsj.com/coronavirus.
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Language Assistance 101 Language assistance services provide medically qualified interpretation and written assistance to patients and Health Plan of San Joaquin (HPSJ) members with Limited English Proficiency (LEP). Those with LEP either do not speak English or do not speak English well enough to effectively participate in their own health care. Through language assistance services in the individual’s primary language, HPSJ can help them to understand their treatment process, be able to ask questions during medical encounters, and facilitate timely access to all health care services – at no cost! When practice patterns do not include the use of appropriate language assistance services, it impacts the individual patient but also the entire diverse population. We know through research and education that lack of language assistance contributes to health disparities. In order to achieve health equity and bridge the language gap, the use of language assistance should be a part of the treatment plan for Limited English Proficiency patients. This includes individuals who are deaf, hard-of-hearing, visual impaired, disabled or have low health literacy. There are situations where someone other than the patient will need language assistance as well. For example, a parent, spouse, friend, or other caregiver will participate in the patient’s decision making, support or care. If you would like to schedule an interpreter or translator for your HPSJ patient, please call HPSJ Customer Service at 888.936.PLAN (7526), TTY/ TDD 711 at least 5 (five) before the appointment. Customer Service can help Monday – Friday, 8 AM – 5 PM. You can also visit our website at www.hpsj.com/customer-service and complete the ‘Request an Interpreter’ form.
Become An Authorized Vaccinator Today! Health Plan of San Joaquin (HPSJ) wants members to connect with their trusted providers. We are joining with the California Department of Health Care Services (DHCS) to encourage our Provider Network to communicate with members to have them make an appointment for their COVID-19 vaccination. This is also a great point of connection to check-in with patients for medical and/or preventative care issues. This is especially important for children who may have missed some of their crucial check-ins, tests and immunizations. HPSJ members who have barriers with transportation can call HPSJ for assistance. The California Department of Public Health (CDPH) list of professionals currently able to administer COVID-19 vaccines, including conditions for giving the shots, is at http://tinyurl.com/4th2nj3j. The myCAvax program updates for providers are at https://eziz.org/covid/. We are proud to partner with each of our network of providers as our community safely reopens.
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Regulatory Requirement Reminders and Support Health Plan of San Joaquin (HPSJ) has had several changes to the regulatory requirements for billing claims. To support you and assist your billing team with submission rules and common billing issues, here is a summary of the changes. 1. Prior Authorization (PA) Effective June 1, 2021, HPSJ requires prior authorizations for oncology drugs in compliance with CCR Title 28 §1300.67.241. Providers must obtain a prior authorization before rendering services. All claims received after June 1, 2021 will be denied if prior authorizations were not approved prior to rendering services. All claims received after June 1, 2021 will be denied if prior authorizations were not approved prior to rendering services. ¾ The provider alert with the details can be found on our website at www.hpsj.com/pharmacyupdate-oncology-medicine. 2. National Drug Codes (NDC) The Federal Deficit Reduction Act of 2005 (DRA) requires all state Medicaid agencies to collect rebates from drug manufacturers for physician-administered drugs. Collection of rebates is accomplished with the inclusion of National Drug Codes (NDCs) with each claim submitted to Health Plan of San Joaquin. Source: https://files.medical.ca.gov/pubsdoco/ndc/ndc.aspx. ¾ Find NDC information required with submitted claims, along with the DHCS Frequently Asked Questions (FAQs), at https://files.medi-cal.ca.gov/pubsdoco/ndc/ndc.aspx. 3. Other Health Coverage (OHC) Per All Plan Letter (APL) 21-002 and State law, Medi-Cal is the payer of last resort when the member has other health coverage (OHC). Therefore, HPSJ members with OHC must use their OHC before using their Medi-Cal benefits. Effective April 1, 2021, HPSJ is required to make sure providers are identifying and billing the OHC carrier as primary. ¾ The provider alert with the details can be found on our website at www.hpsj.com/reminderand-support-from-hpsj.
Track Claims in Real Time Health Plan of San Joaquin (HPSJ) now has an enhanced, helpful tool for contracted and non-contracted providers to check claims status, outside of the provider portal.
Looking up claims is easy: 1. Go to www.hpsj.com/form-view/43 2. Complete the HIPAA Disclosure Agreement 3. After sending the Agreement, you will be routed to the Claims Look-Up Tool 4. Search the status of as many claims as needed
Data you can search in the Claims Look-Up Tool: • • • •
Claim Number Status Receive Date Process Date
• Amount Paid • Check Number - NOW AVAILABLE • Denial Reasons - NOW AVAILABLE
Full details also are available on your Remittance Advice.
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