Detailed information on Behavioral Health Prior Authorization, Utilization Management and Appeals Process changes, Payment Electronic Delivery, Narcan and Naloxone, 2020 Drug Formulary changes, Pharmacy updates, Member Rights & Responsibilities and our Claims Services Associates Team.
Behavioral Health; Prior Authorization, Utilization Management, and Appeals Process Changes
Beginning January 1, 2020, all Prior Approval requests, notifications, and Level I and Level II appeals for Behavioral Health Services for Health Options Members will be processed by Community Health Options and should be submitted as described below. An updated Behavioral Health Notification/Prior Approval form and FAQs have been mailed to providers. Additional information is available on our Provider portal.
|Prior Approval Requests||Submit via the Provider Portal at https://Provider.HealthOptions.org or fax to (877) 314-5693.|
|Urgent Prior Approval Requests||Submit by phone at (855) 542-0880. Urgent requests are those based on clinical presentations that could seriously jeopardize the Member’s life or health, ability to regain maximum function, or subject the Member to severe pain that cannot be adequately managed without the requested care or treatment.|
|Level I and Level II Appeals||Submit via postal mail addressed to Mailstop 800, PO Box 1121, Lewiston, Maine 04243; by email to email@example.com; or by phone at (207) 402-3755.|
Health Options continues to utilize the MaineHealth ACO Behavioral Health Care Program (BHCP) network. BHCP manages contracting, credentialing, and associated updates for BHCP network providers.
All Provider Payments Transitioning to Electronic Delivery
Health Options will be transitioning delivery of all provider payments to electronic methods by January 2020. Providers or facilities that are currently receiving payment by EFT will not experience any change in payment delivery. Providers or facilities that receive payment by paper checks will transition to virtual card payments, or may choose to sign up for faster payments via EFT by visiting: https://register.instamed.com/eraeft
No-Cost Narcan and Naloxone for Health Options Members
Community Health Options has expanded its pharmacy benefit for Members to fill prescriptions for overdose-reversing medications naloxone and Narcan with no co-pay or out-of-pocket expense. This eliminates cost as a hurdle to obtaining these life-saving drugs at a time when Maine is among the states hardest hit by the opioid epidemic. Go to https://healthoptions.org/mediapath/newsroom_pressreleases/pr_2019-09-20_overcoming_the_opioid_crisis/ to view the press release on this benefit.
2020 Prescription Drug Formulary Changes
The medications shown in the table below will be removed from the formulary effective January 1, 2020. Members who are impacted by these changes have been notified by mail and were informed about formulary alternatives where available.
The following drugs are being removed from the formulary effective January 1, 2020
|Drug Name||New Formulary Status||Preferred Alternative 1|
|AMBIEN||NON-FORMULARY||ZOLPIDEM TARTRATE (Generic)|
|AUBAGIO||NON-FORMULARY||GILENYA, MAYZENT, TECFIDERA|
|FOCALIN XR||NON-FORMULARY||DEXMETHYLPHENIDATE HCL ER (Generic)|
|NOVOLIN 70-30||NON-FORMULARY||HUMULIN 70-30|
|NOVOLIN N||NON-FORMULARY||HUMULIN N|
|NOVOLIN R||NON-FORMULARY||HUMULIN R|
Health Options full formulary can be accessed at https://www.healthoptions.org/individuals-families/medications/.
Medical Pharmacy Changes
The Prior Approval requirements are being removed for the following J-Codes under the Medical Benefit effective January 1, 2020
|J0640||Leucovorin Calcium||J7308||Aminolaevulinic acid|
A full list of Health Options Prior Approval requirements can be accessed at
Pharmacy Benefit Updates
Because Health Options’ formulary is updated frequently, we recommend that you consult the formulary before writing a prescription for a Health Options Member. This will better enable you to prescribe a covered medication and minimize the Member’s out-of-pocket cost.
Pharmaceutical management information is available in the formulary and includes:
Member Rights & Responsibilities
It is important that our Members understand entitlements under their Health Options plan, including the information they are able to receive and the type of conduct they should expect to encounter. They also need to be aware of their obligations. A Member Rights and Responsibilities document summarizing this material is available to them on the Health Options website. We recommend that providers also review this document, which can be accessed at https://www.healthoptions.org/media/1981/memberrightsandresponsibilties03142019.pdf.
Introducing our Claims Services Associates (CSA) Team
We’ve improved the handling of claims inquiries by establishing a team of Claims Services Associates (CSAs) who can fast-track responses to a wide variety of processing and adjudication questions. The team is composed of experienced Member Services Associates who completed specialized classroom education, obtained side-by-side experience working with claims adjudication staff, and have real-time access to subject matter experts. This equips them to provide single-call resolution to questions they would previously refer to other departments. To speak to a CSA, call (855) 624-6463 and select the claims questions menu option. Your call will bypass the Member Services queue, eliminating or significantly reducing wait time.
With the recent success of Open Enrollment, it's a pleasure to welcome back our reenrolling Members and also welcome thousands of new Members to Community Health Options. We're your Partner for Health and are proud to be the only non-profit health insurer domiciled in Maine.
We are dedicated to providing affordable, high-quality benefits that promote health and wellbeing. You’ll find many of our special health programs and several new programs in our 2019 health plans.