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Products and Programs for Providers, Winter 2019

Oct 30, 2019
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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 appeals@healthoptions.org; 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)
GRANIX NON-FORMULARY NIVESTYM, ZARXIO
LYRICA NON-FORMULARY PREGABALIN (Generic)
NOVOLIN 70-30 NON-FORMULARY HUMULIN 70-30
NOVOLIN N NON-FORMULARY HUMULIN N
NOVOLIN R NON-FORMULARY HUMULIN R
XATMEP NON-FORMULARY METHOTREXATE

 

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

J-Code Drug   J-Code Drug
J0640 Leucovorin Calcium   J7308 Aminolaevulinic acid
J1627 Granisetron   J7512 Prednisone (oral)
J1650 Enoxaparin sodium   J9031 BCG
J2430 Pamidronate disodium   J9130 Dacarbazine
J3030 Sumatriptan succinate   J9209 Mesna
J3475 Magnesium sulfate      

 

A full list of Health Options Prior Approval requirements can be accessed at

https://www.healthoptions.org/providers/resources/.

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:

  • a list of pharmaceuticals, including restrictions and preferences;
  • how to use the pharmaceutical management procedures;
  • an explanation of limits or quotas (if any);
  • how prescribing practitioners must provide information to support an exception request; and
  • the process for generic substitution, therapeutic interchange and step-therapy protocols.

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.

SEE ALSO

One in five American adults experience a mental health issue in their lifetime. Most people with mental and behavioral health issues can get better with treatment. Community Health Options firmly believes in treating the whole person and that’s why we launched Health Options Online, a new behavioral telemedicine program for our Members.