December 2015 Totally Connected….. · Utilization Management Programs Disease Management Programs THC offers the following four disease management programs to our members: 1. Asthma

December 2015 Network Updates

Totally Connected…..

A newsletter for Physician Offices…...

Our Mission: To be the industry leader in providing quality, cost effective health care for our members

2015 - Year in Review

Thank you to our provider community for

your partnership in 2015. Because of your

support, we are happy to highlight some of

our of accomplishments in 2015!

Total Health Care retains its contract as a

Medicaid provider for Wayne, Oakland and

Macomb Counties. The contract takes effect

1/1/2016 and will remain for a minimum of 5

years. THC elected not to pursue a contract

in Genesee county, so our Medicaid lives will

be transferred to another plan effective

1/1/2016; however, THC remains a commer-

cial carrier in Genesee county.

THC successfully implemented a new medical

management tool that provides for greater

transparency regarding approvals for inpatient

admissions and outpatient referrals.

Our network continues to grow! With the ad-

dition of St Joseph Mercy Oakland Hospital,

we have 30 hospitals, over 1100 ancillary

sites, 6000 individual practitioners practicing

out of 2800 clinic locations plus a vast behav-

ioral health network through Value Options.

Partnerships: THC has instituted some

unique partnerships to address our most vul-

nerable populations. We offer community-

based care / home care for our vulnerable and

non-compliant populations to support our pri-

mary care physicians. Ask us for more info!

Coming in 2016

We aren’t resting on our laurels! We have

plenty in store for our providers in the

coming year:

New Provider Portal—coming soon! New ProHEDIS tool for PCPs that will al-

low for self-reporting and easy access to

patient detail.

Updated website with more information

and transparency!

Physician education forums—bringing you

the most up to date information in

healthcare that will impact your practices

Increased PCMH training tools and sup-

port.

New Medicaid ID cards, that feature both

the THC Member ID number and the Med-

icaid recipient ID number:

Quality Improvement / Utilization Management

Page 2

Covered Services to be provided directly by Provider include all in-office services typically provided by a Primary Care Provider as specified in the list-

ing below.

Quality Improvement Program

Total Health Care’s (THC) Quality Improvement Program (Quality Assessment and Performance Im-

provement Program) is based on the principles of continuous quality improvement. The QI Program’s purpose

is to provide a framework that enables THC to ensure Plan members have access to and receive high quality

health care and preventive services that promote wellness. It is designed to meet state and federal require-

ments and is structured to meet accreditation standards. The QI Program applies to all Total Health Care prod-

uct lines.

Annually, Total Health Care evaluates its quality improvement activities and updates the program as nec-

essary. A yearly work plan is developed that reflects specific objectives, activities and performance measure-

ments for improving the quality and safety of clinical care, the quality of service, and member’s experience.

Upon request, THC will provide information to members and practitioners about the QI Program, includ-

ing a description of the QI Program, and a report on the Plan’s progress toward achievement of annual goals.

Information about the Program is also available on THC’s website – www.THCmi.com. Click on the ‘Providers’

tile - under the ‘More Information’ tab click the Documents and Additional Info link, then Quality Improvement.

Utilization Management Policies:

When reviewing medical necessity for clinical services, THC adheres to documented, evidence- based criteria based on national standards in our decision-making processes: InterQual™ criteria for hospital admissions and continued stay reviews MQIC guidelines for office-based services and outpatient surgeries Policies for Medical Benefit Determination approved by THC Quality Committee based on industry

standards

Criteria is available to providers upon request by contacting our Utilization Management Department during normal business hours of 8:30 am to 5 pm or leave a confidential voice message which will be returned the next business day. Providers may discuss any UM requests or decisions with a board certified physician or other appropriate reviewer . All UM decisions are based solely on medical ap-propriateness and benefit coverage. THC does not specifically reward practitioners, UM decision makers or any other individuals for denying covered services or care.

UM staff identify themselves by name, title and organization name when initiating or returning

phone calls regarding and Utilization Management issues.

TDD/TTY services are available for members who need them.

Language assistance is available to discuss UM issues with members.

Call 800-826-2862

Utilization Management Programs

Disease Management Programs

THC offers the following four disease management programs to our members:

1. Asthma (adult and children)

2. COPD

Members identified through claims analysis are sent a welcome letter with disease-specific educational

materials. Nurses and other support staff provide outreach and education to help members understand

and self-manage their disease processes through health-coaching. The programs are voluntary and

members can self-enroll online through our Member Portal available on the THC website. Members are

enrolled for up to one year or until goals have been met. Providers may also recommend members for

these programs. Contact THC and let us know who you may want to enroll. We will do the rest!

Provider Partnerships Help Manage High-Risk Members

THC is pleased to announce that we have several new partnerships with community-based organizations

that can help reach high-risk members! These partnerships provide enhanced access to health services

and quality of life for complex populations by removing barriers to receiving care. A community health

needs assessment is conducted to develop a person-centered plans that address health goals and social

determinants impacting member health (such as food, housing or behavioral health issues).

Members who do not visit their PCP, are non-responsive to telephonic intervention or those with numer-

ous ER visits and/or hospitalizations are ideal candidates for these programs. THC will proactively enroll

members in these plans, but PCPs can also recommend members; members must agree to participate.

THC will inform PCPs when members are enrolled in these programs.

*************************************************************************************

Alcohol and Substance Abuse

THC providers with Medicaid members who have Alcohol and Substance Use Disorders can refer patients

to one of the Tri-county Health Authorities in THC’s services areas:

Detroit Wayne Mental Health Authority Access Line: 800-241-4949

Oakland County CMH Authority Access Line PACE: 248-858-5200

Macomb County CMH Services Access Center Line: 586-948-0222

Commercial member in need of Substance Use services/referrals contact Beacon Health Options Referral

Line: 1-855-377-2416.

THC also has clinical case managers that can assist you with care coordination for your member’s sub-

stance use needs. Call 313-871-2000 and ask to be connected to a case manager.

Page 3

3. Diabetes 4. Hypertension

Clinical Practice Guidelines

Total Health Care continues to implement clinical practice guidelines and performance measures focused on ef-

fecting positive health outcomes. These guidelines are meant as guidelines. Individual patient considerations

may supersede or modify these recommendations. The following CPGs have been developed by MQIC (Michigan

Quality Improvement Consortium) and recently been approved for use by our Quality Improvement Committee:

Adult Preventive Services (Ages 18-49)

Adult Preventive Services (Age > 50)

Diagnosis of ADHD for Children and Adolescents

Treatment of ADHD for Children and Adolescents

Routine Preventive Services for Infants and Children (Birth-

24Months)

Routine Preventive Services for Children and Adolescents

(Ages 2-21)

Access to these and other approved MQIC guidelines is available through the THC website – www.THCmi.com >

Provider Page > Clinical Resources.

Talking with Parents about Childhood Immuniza-

tions

Physicians (and other health care professionals) play

key roles in keeping parents informed about the im-

portance of vaccination and maintaining high vaccina-

tion rates. According to the Michigan Department of

Health and Human Services, in 2013 and 2014, Michi-

gan had the highest rate of kindergarten vaccine waiv-

ers in the country at 5.9 percent compared with the na-

tional median at 1.8 percent. Three-quarters of the

waivers were for philosophical, not religious or medical

reasons. Three-quarters of children in licensed day

care are in centers where less than 95 percent of the

children are fully vaccinated, which is the Centers for

Disease Control and Prevention federal benchmark. As

a result, nearly 45 percent of Michigan residents are at

risk of a preventable disease outbreak.

Opportunities to start a dialogue with parents about

vaccines include prenatal and postpartum visits, where

you can provide informational materials for parents to

take home and study, or direct them to informational

websites. Flexibility in regards to the parents’ needs

and schedule are also important. Rescheduling a vac-

cine for another day is preferable to not getting the vac-

cine at all. If parents are worried or extremely doubtful,

follow up after the visit to reinforce trust, and make sure

parents are aware of the risks to others as well as their

responsibilities should they choose not to vaccinate.

For additional information and resources visit http://

ww.cdc.gov/vaccines/conversations.

MQIC App Version 1.1 Now Available

The Michigan Quality Improvement Consortium (MQIC) has

developed an app that features evidence-based clinical prac-

tice guidelines and physician tools that can be accessed from

Android and iPhone mobile devices. These tools can be down-

loaded for access when offline and not connected to any Wi-

Fi for mobile networks. The app contains a sync feature allow-

ing for easy, automatic updates of previously-downloaded

Clinical Guidelines

Vaccines, continued

Parents justifiably have questions and concerns about

the necessity and efficacy of vaccines for their children,

and they trust you as their primary health care provider

to give them accurate information. When it is time for

vaccinations, it is important to take time to listen, wel-

come questions to adequately address the parents’ con-

cerns, and acknowledge their role in managing their

child’s health.

You may hear questions from parents regarding the link

between the MMR vaccine and autism, whether vac-

cines are more dangerous to infants than the disease

itself, why there are so many vaccines, vaccine ingredi-

ents, and side effects. The Centers for Disease Control,

along with the Department of Health and Human Ser-

vices, the American Academy of Family Physicians, and

the American Academy of Pediatrics have developed a

tool to assist you with communicating with parents

about vaccinating their infants. This tool can be found at

http://www.cdc.gov/vaccines/hcp/patient-ed/

conversations/downloads/talk-infants-color-office.pdf

Management of Diabetes Mellitus

Management of Overweight & Obesity in

the Adult

Prevention of Unintended Pregnancy in

Adults 18 Years and Older

In office Use of Sedation

Page 4

Treatment of Upper Respiratory Tract Infections in Children and Adults There are millions of visits to family physicians and pediatricians yearly due to upper respiratory tract infec-

tions, including otitis media, group A streptococcal pharyngitis, epiglottitis, bronchitis caused by pertussis,

rhinosinusitis, laryngitis, and the common cold. Most common in the fall and winter, uncomplicated URIs ac-

count for 25 million physician visits and 20 to 22 million sick days lost from work and school each year in the

U.S. Although the majority of URIs are viral, antibiotics are prescribed in up to 65 percent of cases.1 While

antibiotics are necessary in some instances, they are greatly overused and not necessary, which can lead to

resistance, increased cost, and increased adverse effects, including anaphylaxis.

In children, the most common URIs are acute otitis media, acute bacterial rhinosinusitis, and group A strep-

tococcal pharyngitis. The American Academy of Pediatrics established a set of 3 basic principles for the ef-

fective use of antibiotics to treat pediatric URIs in 2013, including:

Accurate diagnosis of a bacterial infection,

Consideration of the risks vs. benefits of antibiotic treatment, and

Implementation of judicious prescribing strategies, including selection of the most effective antibiotic, pre-

scription of an appropriate dose, and treating for the shortest possible duration. 2

The most common types of URIs, along with symptoms and treatment recommendations, are outlined be-

low.

Clinical Recommendations for Practice*

*According to the American Academy of Pediatrics, American Academy of Family Physicians, American Col-

lege of Physicians-American Society of Internal Medicine, Centers for Disease Control, Infectious Diseases

Society of America, National Institute for Health and Clinical Excellence, University of Michigan Health Sys-

tem, Institute for Clinical Systems Improvement, and the American College of Chest Physicians (ACCP).

Many URIs can be treated at home with rest, increased intake of fluids, use of OTC drugs such as aceta-

minophen, NSAIDs , antihistamines and nasal sprays, antitussives and decongestants, and even honey and

lemon. Steroids are sometimes used to reduce airway inflammation and decrease congestion. Simple tech-

niques such as proper handwashing and covering the nose and mouth when coughing or sneezing can re-

duce the spread of URIs.

Gill JM, Fleischut P, Haas S, Pellini B, Crawford A, Nash DB. Use of antibiotics for adult upper respiratory infections in outpatient settings: a national ambulatory network study. Fam Med. 2006;38(5):349–354.

Hersh AL, Jackson MA, Hicks LA. Principles of Judicious Antibiotic Prescribing for Bacterial Upper Respiratory Tract Infections in Pediatrics. Pediatrics. 2013 Nov 18.

Clinical Guidelines

Vitamins & Supplements

Select vitamins are covered for beneficiaries in the Children’s

Special Healthcare System (CSHCS) program as indicated on

the MPPL. Prenatal vitamins are available for coverage for

women of child-bearing age. Vitamin D, Flouride and Folic

Acid are also available.

Page 5

In-Network Laboratory Policy in Effect for 2016 THC has an extensive network of participating laboratories, including all our contracted hospitals (see below). All laboratory benefits for THC members can be received through one of these resources. Therefore, referring a service to an out of network laboratory is not necessary, and is not a benefit. Accordingly, effective in 2016, THC will implement the following policy related to claims for out of network labs: Any lab specimen for a commercial member that is sent or referred by a phy-

sician’s office to an out of network lab will be paid and charged back to the ordering physician. Out of network labs for Medicaid members will be de-nied.

Physicians will be reviewed for compliance in the first quarter of 2016. Any

physician who referred a patient or specimen to an out of network laboratory will be contacted and given a courtesy reminder for the first instance. There-after, any out of network lab will be processed and paid according to THC’s fee schedule, and charged back to the provider. Payment will be applied to-wards future claims.

Physicians can perform in-office labs for any CLIA waived test.

In Network Laboratory ServicesIn Network Laboratory ServicesIn Network Laboratory Services

Hospital Laboratories and affiliated sites: Beaumont Hospital Dearborn Beaumont Hospital Farmington Beaumont Hospital Grosse Pointe Beaumont Hospital Royal Oak Beaumont Hospital Troy Beaumont Hospital Taylor Beaumont Hospital Trenton Beaumont Hospital Wayne Detroit Receiving Hospital Harper University Hospital Hutzel Women’s Hospital Children’s Hospital of Michigan Sinai Grace Hospital Huron-Valley Sinai Hospital

Quest laboratories - any location Page 6

Laboratory Policy - NEW

St John Hospital & Medical Center St John Hospital Macomb Oakland Hospital St John River District Hospital Providence Hospital & Medical Center Providence Park Hospital Crittenton Hospital Garden City Hospital St Mary’s of Livonia St Joseph Mercy Oakland Mercy Memorial Hospital - Monroe Barbara Ann Karmanos Cancer Institute Hurley Hospital Doctor’s Hospital of Michigan

News You Can Use

Page 7

Primary Care Uplift continues for 2016

The Primary Care Uplift payment as provided for in the Affordable Care Act has been extended for 2016!

PCPs who are contracted with THC for Medicaid are eligible for to receive an enhanced payment on

specific evaluation & management (E&M) codes when billing for the service. In order to be eligible for

the uplift payment, the following must be true:

Provider must be contracted as a PCP with Total Health Care under the specialty of

Internal Medicine

Family Medicine

Pediatrics

General Practice

Geriatrics

Provider must be Eligible in Champs

Provider must be in-network

If you have any questions, please contact your Provider Relations Representative.

Credentialing Process

Total Health Care has established minimum

standards for participation in its contracted pro-

vider network. Providers (MD/DO/DDS/DPM/

DC) are required to sign a contract, submit a

completed Physician Credentialing Application

and/or allow THC to access the CAQH applica-

tion online, and must have medical staff privi-

leges at an in-network hospital. Upon primary

source verification of required documents, an

office site visit will be conducted to assess mini-

mum office requirements, including safety and

record keeping. Additional inquiries will be

made to the National Practitioner Data Bank

and Healthcare Integrity and Protection Data

Bank. All of the aforementioned information is

then reviewed by the Credentialing Committee.

Upon approval by the Committee, which is com-

prised of participating physicians, providers re-

ceive a Welcome Letter and effective date with

the plan. Providers who are denied participa-

tion have the right to Appeal.

Did you Know…….

Language interpretation services (either writ-

ten or spoken) are made available to mem-

bers in any setting (ambulatory, inpatient and

outpatient).

To obtain an interpreter for a deaf patient:

The PCP office must contact our Customer

Services Dept. 1-2 weeks prior to the mem-

ber’s appt. to schedule with the interpret-

er. Our Customer Services Dept. will make

the arrangements. The cost is covered by

THC.

Physician Assistants and Nurse Practitioners

can serve as Primary Care Physicians with pa-

tient assignment. Every provider must be

contracted and credentialed. PAs are required

to have a contracted supervising physician in

order to have patient assignment.

PCPs must be available for a minimum of 20

hours at every contracted location in order to

see Medicaid members.

MiChild and Medicaid Expansion Effective January 1, 2016, MiChild has been incorporated into Medicaid as part of the Medicaid ex-

pansion program. Accordingly, MiChild members will no longer have acupuncture coverage, and

the rest of their benefits mirror those of Medicaid members, include Mental Health benefits. Please

do not accept a THC ID card with Group Numbers of M8000 or M8000, which previously represent-

ed MiChild. All MiChild members have an new ID card with the Medicaid Recipient ID number as

shown on Page 1 of this newsletter.

More News

Health Coverage Grievance and Appeal Rights

THC adheres to the Department of Insurance and Financial Services (DIFS) internal and external

grievance and appeal processes. Patients have the right to an independent review when an ad-

verse determination has been denied through the internal grievance process with Total Health

Care. The PRIRA (Patient’s Right to Independent Review Act) provides for an external review

through DIFS, and members can authorize a representative, such as a physician, to represent

them in the process. For more information about this process, visit www.michigan.gov > Con-

sumers > Health Insurance Information. You can also find our Appeal Process outlines online at

www.THCmi.com.

Michigan Healthcare Referral Form - Its gone the way of the Dirigible and ICD-9!

All good things come to an end. Remember the Michigan Healthcare Re-

ferral Form (also known as the Universal Referral Form)? In its day, it

was quite innovative.

The form was created and copyrighted in 1999 by the Michigan Associa-

tion of Health Plans in a collaborative effort between managed care com-

panies and area hospital systems

throughout Michigan. This effort was aimed at reducing costs and

streamlining referrals to specialists.

Alas, the form has outlived it purpose. It is no longer supported by the

Michigan Association of Health Plans (MAHP) and is not available on the

MAHP Web Site. Please DO NOT use the form any longer, particularly

for Medicaid FFS members. Please discard any copies of the form.

Page 8

Access to Care Standards

PRACTICE GUIDELINES AND STANRDS

A. Access and Availability

Total Health Care is committed to ensuring our members have access to the right care at the right place and in a timely manner. THC has developed the following standards which define appropriate access to medical care warranted by the severity of a patient’s illness or medical condition. The ease with which members can access services based on the following timeframe expectations is a quality standard that will be monitored for our primary care physicians:

B. EPSDT/Well-Child Guidelines Well-child care and immunizations are an important component of a preventive care program. Total Health Care supports EPSDT Guidelines and expects PCPs to promote and schedule age-appropriate well-child exams and immunizations. Immunizations must be appropriately docu-mented in the medical record and reported to the Michigan Care Immunization Registry (MCIR) as required by State law. Vaccines are available through the State of Michigan’s Vac-cinations for Children’s Program for those who qualify.

C. Preventive Health Guidelines

To encourage the appropriate delivery and use of preventive services at appropriate intervals, Total Health Care has adopted and implemented preventive health guidelines for prevention and early detection of illnesses. The use of preventive health guidelines is an essential component to help reduce the incidence of illness, disease, and accidents. Early detection of potentially serious illnesses may reduce the impact of illness on the member and associated health care costs. Ad-ditionally, use of preventive health guidelines has the potential to reduce unwanted variation in health care out- comes.

Primary Care Physician Response Standards

Regular and Routine Care Appointments (i.e. preventive/well-care,

routine non-symptomatic, physical, annual GYN exam)

Within thirty (30) days

Routine Non-Urgent (i.e. symptomatic ) Within seven (7) days

Urgent Care Appointments (i.e. persistent diarrhea/vomiting, high

fever)

Within twenty-four (24) hours

Emergency Care (i.e. life-threatening conditions) Twenty-four (24) hours/ seven (7)

days a week at any hospital

Office Visit Wait Time for Scheduled Appointments Within 15 minutes, members should be

taken to the exam room. Within 30 minutes, members should be

seen by their doctor

Page 9

Discharge process

We require primary care providers (PCPs) to follow the following steps to discharge a member

from their practice. Note: You may not contact members about discharge until Total

Health Care has approved the discharge.

Document the reason(s) for requesting discharge within the member’s practice record.

Document all resolution attempts within the member’s practice record.

Attach copies of your documentation from the member’s record indicating reason for re-

quest and resolution attempts.

THC will review your request and documentation promptly.

You will receive an approval or denial for each request.

Notify the member that he or she has been discharged from your practice.

You must offer 30 days of urgent/emergent care to the member following the discharge

date.

THC will reassign members to a new PCP. Typically, the new PCP assignment is effective on

the first day of the first month after the 30-day discharge period.

Acceptable reasons for discharge

Discharge requests are automatically approved for the following reasons:

Unpaid copayments or deductibles, with a minimum of a 90-day collection period. Collection

attempts must be documented.

Persistent non-compliance with a documented care plan which results in unnecessary utili-

zation of health care resources. Non-compliance and steps to educate the member on ap-

propriate use of primary care must be documented.

Repeated “no-shows” for scheduled appointments. This is defined as three or more visits

missed in a twelve month period. Dates of no-shows must be documented.

Threatening behavior displayed toward practice staff. Behavior and practice response must

be documented.

Members previously discharged from the practice, prior to coverage with THC.

Fraudulent behavior, with the case documented in the member’s record.

Cases that will be referred for special programs

“Doctor-shopping” to obtain prescriptions. Details of this activity should be documented in-

cluding dates of visit or contact with the member.

Failed drug screen, in violation of practice illegal drug-free policy. Date of drug screen and

policy must be documented.

Patient Dismissal Policy

Page 10

Pharmacy Lockout - Does Your Patient Qualify?

Pharmacy Lockouts allow providers to manage their patient’s medication use by controlling prescription du-

plications, drug seeking behavior and cost, while additionally helping to prevent fraud and/or abuse. A Pro-

vider may request THC to place a pharmacy lockout on a patient’s prescription file for the following circum-

stances:

Patient seeking controlled substances from multiple providers

Fraud on prescription drugs

The pharmacy lockout enables only specific named providers to prescribe medications to a patient; thereby

locking out all other providers from whom the member may seek unnecessary or duplicate medication.

THC can implement a pharmacy lockout for all medications or target the lock out to a specific therapeutic

drug class. This option allows any provider to prescribe medications except for the designated drug class ex-

clusion. For example, the Primary Care Physician may choose to be the sole prescriber of controlled sub-

stances for their member.

To initiate a pharmacy lockout, THC requires the NPI number of the provider(s) you wish to include. Multiple

NPI numbers can be entered for a lockout. Call the Pharmacy Department 313-871-2000, extension 3300 for

questions or to implement a pharmacy lockout.

Drug Exception / Prior Authorization Criteria

THC’s Pharmacy Department ensures that drugs provided to members are medically necessary and

appropriate. Under the direction of the Medical Director, Pharmacy staff consistently applies THC writ-

ten criteria when making benefit and medical necessity determinations. The criteria are based on

facts and nationally accepted standards. Coverage denials are made by a board certified physician. You

may request a Drug Exception or Prior Authorization if the use of other formulary agents is contraindicated in

the member, if a member failed current formulary options as listed in the Therapeutic Drug Formulary or the

continued use of current formulary options would be of no clinical benefit for the member. Prior Authoriza-

tion Criteria for prescription drugs is available to providers upon request by contacting the Pharmacy Depart-

ment in writing or by calling THC at 800-826-2862, press extension 3300.

Pharmaceutical Management Procedures

Please visit THC’s web site at www.THCmi.com to view Condensed and Expanded Drug Formu-laries for: Commercial CSHCS Medicaid which include pharmaceutical management procedures on generic substitution, step therapy, quan-tity limits, and prior authorization requests.

Pharmacy Updates

Page 11

NDC Requirement - Comply to Avoid Claim Rejection All providers are required to report the National Drug Code (NDC) in addition to the procedure

code (CPT or HCPCS) when billing for a physician administered drug on the electronic and paper claim

formats. The NDC is a unique 11-digit identifier assigned to a drug product by the labeler/ manufacturer

under Federal Drug Administration (FDA) regulations. The NDC number of the product actually dis-

pensed must be billed. The NDC number is package size and Label specific. This requirement is mandat-

ed to ensure the Michigan Department of Community Health's compliance with the Patient Protection

and Affordable Care Act (PPACA). The PPACA requires Medicaid to collect rebates for certain drugs.

The NDC (11-digit code with 5-4-2 format) must be reported on a claim as follows:

11-digit NDC number

Unit price (EDI only)

2-digit unit of measure code, e.g., GR (Gram), ML (milliliter), UN (Unit)

Quantity dispensed

On Professional claims, report:

Electronic - Loop 2410, Segment LIN, Data Element LIN03

Paper - Box 24A shaded area.

On Institutional claims:

Electronic - Loop 2410, Segment LIN, Data Element LIN03;

Paper - Box 43

Please note, the reporting of the NDC is not required for CPTs that are considered packaged or bundled

under the Outpatient Prospective Payment System (OPPS).

Visit www.dmepdac.com/crosswalk for an up-to-date list of how to report this information.

Pharmacy

Envision Pharmacy Help Desk 844-222-5584 Mail Order Pharmacy 866-909-5170 Diplomat Specialty Pharmacy 877-977-9118 J & B Medical Supply (Diabetic Supplies) 844-236-7933 THC Pharmacy Department 313-871-2000, ext 3300 (THC staff are available Mon-Fri 8:30 - 5 pm. Communications received after 5 pm will be re-

spond to

Page 12

January 2016 Formulary Updates:

Effective November 1, 2015

All Qualified Health Plan (Exchange) prior authorizations will be subject to a review period of no greater than 72

hours for standard requests and no greater than 24 hours for urgent requests. In an effort to conduct the highest

level of quality review within these timeframes, please submit all applicable chart notes and labs along with the THC

prior authorization form.

THC has updated the fax number on the Standard and QHP (Exchange) prior authorization forms. The forms, which continue to be located at https://thcmi.com/pharmacy-providers, may be faxed for review to 1-866-414-3453.

Pharmacy Updates

Medication Update

Formulary Affected

Medicaid /

CSHCS Commercial 3-Tier QHP (Exchange)

Sulfacetamide Sodium

10% Ophthalmic Solu-

tion

Added to the Formulary. X

Istalol 0.5% Ophthal-

mic Solution Removed from the Formulary. X

Fluorometholone 0.1%

Ophthalmic Suspension Added to the Formulary. X

FML Forte 0.25% Oph-

thalmic Suspension Removed from the Formulary. X X

X

Prednisolone Sodium

Phosphate 1% Ophthal-

mic Solution Added to the Formulary. X X

Blephamide Ophthal-

mic Suspension Removed from the Formulary. X X X

Lumigan 0.01% Solu-

tion

Removed from the Formulary. X

Bimatoprost 0.03% So-

lution

Added to the Formulary with Step

Therapy (ST) requirement of prior ther-

apy with Xalatan. X X X

X

Travoprost 0.004% So-

lution

Added to the Formulary with ST re-

quirement of therapy with Xalatan. X X X

X

Travatan-Z 0.004%

Solution Removed from the Formulary. X

Epinastine 0.05% Drops Added to the Formulary. X X X

Cystaran 0.44% Solu-

tion

Removed from the Formulary. X

Promethazine Supposi-

tories

Added Quantity Limit (QL) of 28 sup-

positories per 14 days. X X X

Claritin 10mg Capsules Removed (Loratadine tablets and solu-

tion are covered). X X

Claritin 5mg Chewables

and 5mg Reditabs

Removed (Loratadine tablets and solu-

tion are covered). X X X

Loratadine 5mg/5mL Added to the Formulary. X

Levocetirizine 5mg Added with QL of one tablet daily. X X X X

Daraprim 25mg Removed QL and Added PA. X X X

Striverdi Added with QL of #1 inhaler per

month

X X X

X

Theophylline Elixer Removed from the Formulary. X X X

Theophylline Solution Added to the Formulary. X X X

Page 13

ICD 10—It Came and It Stayed!

Congratulations to our providers. ICD-10

seems to have gone smoothly. If you have

any questions or concerns with filing your

claims with THC, please call our claims de-

partment.

Page 14

Policy Total Health Care, through its Compliance program and other policies, is committed to the reduc-

tion of waste, fraud and abuse in the healthcare system. As a health plan that receives federal

funds, Total Health Care is responsible for establishing and disseminating detailed information re-

garding Federal and State False Claims Acts and related whistleblower protection laws to all em-

ployees, associates, agents and contractors.

False Claims Act – What You Should Know

What is it? The False Claim Act is a federal law that makes it a crime for any person or organiza-

tion to knowingly make a false record or file a false claim regarding any federal health care pro-

gram. Due to our participation in both the Medicare and Medicaid programs, Total Health Care is

subject to enforce the False claim act which pertains to any plan or program that provides health

benefits, whether directly, through insurance or otherwise, funded directly, in whole or in part, by

the United States Government or any state healthcare system. Knowingly includes having actual

knowledge that a claim is false or acting with “reckless disregard” as to whether a claim is false.

In addition to the federal law, the state has adopted similar laws under the Michigan Medicaid

False Claims Act (MMFCA). The MMFCA is designed to prevent fraud, kickbacks and conspira-

cies in connection with the Medicaid program.

Examples of false claims include billing for services not provided, billing for the same service more

than once or making false statements to obtain payment for services.

Penalties under the False Claims Act. Violations under the federal False Claims Act can result

in significant fines and penalties. Financial penalties to the person or organization include recovery

of three times the amount of the false claim(s), plus an additional penalty of $5,500 to $11,000 per

claim.

Violation of the MMFCA constitutes a felony punishable by imprisonment, or a fine of $50,000 or

less, or both, for each violation. Any person who receives a benefit by reason of fraud,makes a

fraudulent statement, or knowingly conceals a material fact is liable to the state for a civil penalty

equal to the full amount received plus triple damages.

Fraud, Waste & Abuse

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Total Health Care Team

Clinical Operations Robyn Arrington, MD Medical Director 313-871-7801 Harold Arrington, MD Associate Medical Director 313-293-6474 Linda Alexander, RN Chief Clinical Officer 313-293-6460 Anita Nesby-Flowers, RN Manager, Case Management 313-871-7817 Nicole Marshick, RN Manager, Quality Improvement 313-293-6463 Pharmacy Justin Bentley Pharmacy Dept. 313-871-7885

Claims LaDawn Wyatt Claims Manager 313-871-7877 Provider Network Services Susan Ryan Manager 313-871-6589 Anita Wallace Provider Relations Representatives 313-871-7809 Networks: Oakwood UOP Independent Physician Practices A-M Monroe Allied Physicians Pamela Long Provider Relations Representatives 313-293-6440 Networks: Beaumont St John Providence United Physicians OPNS PMC Brittaney Shiller Provider Relations Representatives 313-293-6443 Networks: DMC PHO Olympia OSP Wayne State University Physicians Group Independent Physician Practices N-Z Judith Idris Provider Relations Phone Representative 313-871-7831 Christina Pittinato Credentialing 313-871-7889 Substance Abuse Line

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