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Quality Updates for Providers, Fall 2019

Sep 04, 2019
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Important information on upcoming provider and Member outreach, the Risk Adjustment program, Support Services available, Utilization Management help, and our Annual Affirmative Statement.

Upcoming provider and Member outreach

To improve future compliance with our CMS-mandated Health Effectiveness Data and Information Set (HEDIS) requirements, Health Options will send supplemental data requests to providers to validate compliance with following measures: 

  • Avoidance of antibiotics for bronchitis/URI
  • Appropriate testing for pharyngitis to confirm need for prescriptive antibiotics
  • Avoidance of imaging for initial 28 days of low back pain
  • Timely follow-up for Members newly prescribed ADHD medications

Health Options will also be communicating directly with Members to inform them about gaps in diabetic care and children’s wellness visits.

HEDIS Measures can be accessed here and guidance on antibiotic avoidance is available from Choosing Wisely.

Completion of gap closure forms for Health Options’ 2019 Risk Adjustment Program

Health Options routinely reviews records to identify Members with high-risk conditions and that appear to have gaps in care. We actively outreach to identified Members and will promote the need to schedule a well visit with their PCP by the close of 2019. Members may obtain scheduling assistance from our Medical Management team and from our partner, Indegene. 

Gap Closure forms are sent to the Member’s PCP of record. If you receive one or more of these forms, please encourage the indicated patient(s) to schedule the needed appointment.

After the visit we ask that you complete the Gap Closure form, making sure to document any chronic conditions, and return it as indicated. If you have any questions regarding Risk Adjustment, please contact Deidre DeRoche, Manager, Government Programs at dderoche@healthoptions.org.

Support Services Available from Health Options

Health Options’ Medical Management team offers a wide array of services to support Members’ overall health that include:

  • Complex Case Management for Members experiencing catastrophic diagnoses or extensive use of healthcare resources
  • Care Management programs for Members facing metastatic cancers, transplants, and pediatric intensive care unit admissions

Other areas of healthcare that support services are available include (but are not limited to): Transitions of Care, Behavioral Health, Substance Use, Cancer Care, Maternity, Disease Management, and Point of Service. Members can request services and providers can refer Members by contacting Health Options Member Services, Monday – Friday, 8am – 6pm, at 855-624-6463.

Utilization Management Questions Answered

Answers to questions about utilization management, prior authorization requirements, and clinical criteria are available from Health Options’ Utilization Management team, Monday – Friday, 8am-5pm, at 855-542-0880.

Annual Affirmative Statement

Medical Management staff involved in the prior authorization process must annually sign the following Non-Inducement/Affirmative Statement:

“Health Options’ prior authorization determinations are based on the medical necessity of care utilizing evidenced-based guidelines and existence of benefits based on Member’s health plan. Health Options does not pay or give incentives to our employees or contracted Providers to improperly deny or withhold benefits.”

SEE ALSO

Detailed information on claims submission pathways and requirements, replacement claims, claims reconsiderations, and new addresses for submitting appeals and reconsiderations.