PreferredOne does not specifically reward practitioners or other individuals for issuing denials of coverage or service care. Financial incentives for utilization management decision-makers do not encourage decisions that result in underutilization. Utilization management decision making is based only on the appropriateness of care and service and existence of coverage.
Minnesota Community Measurement (MNCM) is a collaboration among health plans and provider groups designed to improve the quality of medical care in Minnesota. MNCM’s mission is to accelerate the improvement of health by publicly reporting health care information. MNCM has three goals:
- Reporting the results of health care quality improvement efforts in a fair and reliable way to medical groups, regulators, purchasers and consumers.
- Providing resources to providers and consumers to improve care.
- Increasing the efficiencies of health care reporting in order to use our health care dollars wisely.
PreferredOne is one of seven founding health plan members of MNCM. The state medical association, medical groups, consumers, businesses and health plans are all represented on the organization's board of directors. Data is supplied by participating health plans on an annual basis for use in developing their annual Health Care Quality Report.
MNCM released their 2016 Health Care Quality Report on their website during the first quarter of 2017. The 2016 Health Care Quality report features comparative provider group performance on preventive care screening and chronic disease care. One of the primary objectives of this report is to provide information to support provider group quality improvement. Provider groups will find this report useful to improve health care systems for better patient care. Sharing results with the public provides recognition for provider groups that are doing a good job now and motivates other groups to work harder. The report will allow provider groups to track their progress from year-to-year and to set and measure goals for future health care initiatives. The MNCM website also provides consumers with information regarding their role as active participants in their own care. Visit the MNCM website site to view the 2016 annual report at www.mncm.org.
The mission of the QM Program is to identify and act on opportunities that improve the quality, safety and value of care provided to PreferredOne members, both independently and/or collaboratively, with contracted practitioners and community efforts, and also improve service provided to PreferredOne members and other customers.
PreferredOne's member and physician website will be updated in the near future to offer the following program documents:
- 2017 PreferredOne QM Program Description, Executive Summary
- 2016 Year-End QM Program Evaluation, Executive Summary
To access these documents, log into the Provider site, and then click on the Quality Management Program link under the Information heading.
If you would like to request a paper copy of either of these documents please contact Heather Clark at 763-847-3562 or e-mail us at firstname.lastname@example.org.
PreferredOne has been notified by The Department of Health and Human Services (HHS) that we are required to participate in an Initial Validation Audit (IVA) for a sample of members both on and off the Health Insurance Exchange (HIX). This audit is not specific to you or your practice and is not designed to monitor your practice, your billing or coding patterns.
Cognisight, LLC is the IVA vendor selected to gather medical records on behalf of PreferredOne. Since this is a government mandated audit, it is your obligation to provide medical records or obtain records from your vendor and submit the requested medical records with no charge to PreferredOne or its IVA vendor, Cognisight. Please do NOT mail, fax, or email any invoice/pre-payment invoice requests. Thank you for your cooperation.
We would like to thank all of our provider groups for their cooperation and collaboration during our recent HEDIS medical record review process. We realize that this process is burdensome to clinics and staff and appreciate your willingness in working with our vendor to ensure our HEDIS results for 2017 are accurate. Thank you!
The Integrated Health and Pharmacy and Therapeutics Quality Management Subcommittees approve new criteria sets for use in their respective areas of Integrated Healthcare Services. Quality Management Subcommittee approval is not required when there has been a decision to retire a PreferredOne criteria document or when medical polices are created or revised; approval by the Chief Medical Officer is required. The Quality Management Subcommittees are informed of these decisions.
For the most current versions of the Medical Policy documents, please access the Medical Policy section on the PreferredOne website. (Click Coverage and Benefits then choose Medical Policy) Medical Policy documents are available on the PreferredOne website to members and to providers without prior registration.
Since the last newsletter, the following are the new, revised, or retired Medical Policy documents. Some of the more extensive Medical Policy updates are detailed for a few of the items below. If you wish to have paper copies of these documents, or you have questions, please contact the Medical Policy Department telephonically at (763) 847-3386 or online at Heather.Hartwig-Caulley@PreferredOne.com.
Durable Medical Equipment, Prosthetics, Orthotics, and Supplies List
- No revisions
- Medical Criteria
- MC/B002 Orthognathic Surgery – Revised to specify the degree of vertical overlap of anterior teeth.
- MC/G001 Eyelid and Brow Surgery – Revised to add medical necessity criteria for other indications for blepharoplasty.
- MC/G008 Hyperhidrosis Surgery – Revised to reflect a more specific requirement related to the trial of aluminum chloride and iontophoresis.
- MC/I007 Cryoablation/Cryosurgery for Oncology Indications – Revised to include additional proven effective indications for cryoablation for certain skin cancers.
- MC/I009 Deep Brain Stimulation – Revised to specify the absence of severe dementia in members with Parkinson Disease.
- MC/K001 Intravenous Antibiotic Therapy for Lyme Disease – Revised to clearly identify CDC as the source of guidance for Lyme disease testing and to reflect the criteria for testing from the CDC.
- MC/L010 Genetic Testing for Hereditary Cancer Syndromes – Multiple revisions have been made to this criteria document, reflecting current guidelines from NCCN.
- MC/L015 Comparative Genomic Hybridization (CGH) – Revised to reflect that karyotyping is no longer required before CGH.
- MC/M001 Mental Health Disorders: Inpatient Treatment – Revised to combine information into a single entry.
- MC/M023 Mental Health Disorders: Intensive Residential Treatment Services (IRTS) – Revised to reflect appropriateness criteria of the IRTS level of care for members 17 years of age and transitioning to adult mental health services, and as captured in the DHS IRTS guideline.
- Medical Policy
- MP/D004 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) – Revised to reflect language in the Certificate of Coverage/Summary Plan Description and exclusions regarding activities of daily living. This policy was also revised to include a statement referring to frequency on the DMEPOS List.
- MP/I001 Investigative Services – Revised to reflect that newly released CPT and HCPCS codes for emerging technology, services, and procedures, such as but not limited to Category III and other temporary codes may be designated as excluded, upon release, until PreferredOne has determined if reliable evidence permits conclusions concerning its safety, effectiveness, or effect on health outcomes.
- Congestive Heart Failure, Invasive Monitorin
- Congestive Heart Failure, Non-Invasive Telemonitoring
- Interspinous and interlaminar distraction devices
- Interspinous fixation devices
- Varicose vein procedures
- Endomechanical or mechanicochemical ablation (MOCA), eg, ClariVein
- Medical adhesive treatments, eg, VenaSeal Closure System
- Micronized purified flavonoid fraction (MPFF)
- VeinGogh Ohmic Thermolysis
- Revision: Amniotic membrane allograft for all indications except corneal grafting and the use of a multi-layer biologic dehydrated human amniotic membrane allograft (such as, but not limited to, EpiFix) for diabetic foot ulcers
- Pharmacy Criteria – The criteria documents for coverage of drug requests under the Pharmacy benefit are available at PreferredOne.com, click on Coverage and Benefits, choose Pharmacy Information, then choose Formulary. Pharmacy criteria documents developed for drug requests under the Medical benefit are found in the Medical Policy section on PreferredOne.com.
- Pharmacy Criteria under the Medical Benefit
- PC/A011 Altered Bone Homeostasis Treatment Medications – Revised to separate the medically necessary (M/N) indications for pre-existing conditions that preclude the use of an oral bisphosphonate out from the M/N indications of gastrointestinal reflux disease (GERD) symptoms due to the trial of an oral bisphosphonate.
- PC/R004 Rituxan Prior Authorization – Revised to reflect pemphigus vulgaris as an FDA approved indication for the use of this medication. This was previously allowed under off-label uses.
- Pharmacy Policy
- PP/B002 Biosimilar Products – This policy has been suspended and is undergoing further revision.
If a patient admission/encounter is solely for the administration of chemotherapy, immunotherapy or radiation therapy, assign the appropriate Z51.xx code as the first-listed or principal diagnosis, and the diagnosis or problem for which the service is being performed as a secondary diagnosis. This applies to professional and facility claims.Vaccinations, Immunizations, Immunology
Code Z23 is for encounters for immunizations and vaccinations. It indicates that a patient is being seen to receive a prophylactic inoculation against a disease and should be reported as the primary/prinicipal diagnosis. Procedure codes are required to identify the actual administration of the injection and the type(s) of immunizations given.
Code Z23 may be used as a secondary code if the immunization is given as a routine part of preventive health care, such as a well-baby visit. Any counseling rendered during the encounter would be coded as a secondary diagnosis, not a primary diagnosis using the appropriate counseling “Z” code.Screening Services
Screening is the testing for disease or disease precursors in seemingly well individuals so that early detection and treatment can be provided for those who test positive for the disease (e.g., screening mammogram).
A screening code may be a first-listed code if the reason for the visit is specifically the screening exam. The screening “Z” code indicates that a screening exam is planned. Should a condition be discovered during the screening then the code for the condition may be assigned as an additional diagnosis.
The testing of a person to rule out or confirm a suspected diagnosis because the patient has some sign or symptom is a diagnostic examination, not a screening. In these cases, the sign or symptom is used to explain the reason for the test.Telehealth/Telemedicine/Telecommunications
PreferredOne will allow an E/M service appended with a 25 (significant, separately identifiable service) modifier only when there are multiple diagnoses on the claim form that are appropriately linked to the reported services/procedures.
Please see the attached PreferredOne Reimbursement Policy – Reimbursement for Evaluation & Mgmt Services Provided Concurrently with Procedure or Surgery.AT (Acute Treatment) Modifier for Chiropractic Claims
Effective August 1, 2017, PreferredOne will require the submission of the AT modifier on chiropractic claims in order to distinguish between acute treatment and maintenance therapy.GN, GO, GP Modifiers for PT/OT/SLP Claims
PreferredOne has always required the appropriate modifier be appended to all Physical Therapy (PT), Occupational Therapy (OT), and Speech Language Pathology (SLP) reported services. This allows the appropriate member benefit to be applied during processing. Claims from these providers received without one of the required (below) modifiers will be returned.
GN – Services delivered under an outpatient speech language pathology plan of care
GO – Services delivered under an outpatient occupational therapy plan of care
GP – Services delivered under an outpatient physical therapy plan of careNew codes effective July 1, 2017
Q9984 Levonorgestrel-releasing intrauterine contraceptive system (Kyleena), 19.5 mg
Q9985 Injection, hydroxyprogesterone caproate, not otherwise specified, 10 mg
Q9986 Injection, hydroxyprogesterone caproate (Makena), 10 mg
As part of the effort to combat the opioid epidemic, please note the important state and national updates effective July 1 and August 1, 2017, respectively, for the processing of short acting opioid prescriptions. The following information will outline what both members & their pharmacists may encounter at the pharmacy with this update. Exempt from this update are members in hospice and members with a diagnosis of cancer.Minnesota
Effective July 1, is an amendment to state statute 152.11 that puts limits on days supply of opiates for acute dental and ophthalmic pain to four days. However, in the professional clinical judgment of the practitioner a larger quantity may be issued.Nationally
Patients who are new to short-acting opioid therapy as of August 1, 2017 will be limited to a maximum cumulative daily morphine equivalent dose (MED) of 49mg, a maximum of seven days therapy per Rx, and a maximum of two prescriptions over a 60 day period. The patient will be determined to be new to opioid therapy if they have no long-acting opioids or no more than 1 short-acting prescription in their available prescription history in the past 120 days from the day of the fill.
Patients who are opioid experienced (i.e. not new to opioid therapy) will be limited to maximum cumulative daily morphine equivalent dose (MED) of 90mg and a maximum of two prescriptions over a 60 day period.
Pharmacies filling for patients who then exceed the above criteria may experience rejections of opioid prescriptions based on the National Council for Prescription Drug Plans (NCPDP) standards. Initially, you may expect to receive more calls from members and pharmacies seeking over rides to these limits.