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President’s Message QualCare’s acquisition by Cigna a year ago has led to significant growth for our company and many new, innovative products for our members. It has allowed us to serve clients not just in the region, but also across the country with new products and ultimately, better patient care and outcomes. Our close relationship with the provider community continues to play an invaluable role as we work with Cigna to structure new patient-centered, locally tailored options for employers. We believe as unique, highly coordinated member and provider engagement models continue to be rolled out, there will be measurable improvements in the quality of care, an individual’s health and a lowering of health care costs. An example of this is the recently announced collaboration between Seton Health Plan and Cigna, which will offer insured and self-insured health plans to employers with 51 employees or more in the Austin and Waco, Texas area. In this joint effort, they will employ a clinically integrated and more cost-effective system of care designed to improve patient outcomes while reducing duplication of services and unnecessary cost. Seton Health Plan is using QualCare’s best-in-class administrative platform and service model to coordinate the overall effort. Piedmont Healthcare also selected QualCare to administer its
As we undertake many new efforts with Cigna, QualCare remains committed to supporting our providers in the transition to value based payment models. We were created as a provider based company and your partnership has been a critical element in our continued success. We appreciate your commitment to QualCare and look forward to our continued collaboration.
employee health plan as a way to improve the health and wellbeing of their employees. Piedmont is a private, not-for-profit with six hospitals in Northern Georgia and more than 8,000 employees. QualCare has a 25 year history in managing hospital sponsored employee health plans and will use our customized platform to provide population management programs and other innovations to help Piedmont offer high quality care to its employees.
Sharon Seitzman President
QualCare / Cigna Network Update QualCare’s acquisition by Cigna continues to yield exciting
to improve quality and deliver high quality, coordinated and
and substantial opportunities for our clients both in New
affordable care, as well as an exceptional patient experience.
Jersey and outside of the state. In addition to Cigna’s QualCare
Seton Health Plan’s insured and self-insured offerings will be
Platform being selected to administer Piedmont Healthcare’s
available to employers with 51 or more employees within a 13-
(Atlanta, GA) Employee Health Plan, effective January 1, 2016,
county area served by Austin-based Seton Healthcare Family
another unique collaboration has taken place with Seton
and Waco-based Providence Healthcare Network. The
Health Plan, Inc.
arrangement enables Seton, Providence and Cigna to combine
Seton Health and Cigna have entered into a joint venture agreement, which will utilize QualCare’s best-in-class administration platform, to offer employers in and around Austin and Waco, TX integrated health care products designed
health plan, hospital, clinic, provider and administrative capabilities in a unified effort to improve people’s lives, deliver long-term sustained medical cost savings, and create healthier communities.
Kevin Joyce Promoted to QualCare Chief Operating Officer It is with great pride that QualCare announces the promotion of Kevin Joyce to Chief Operating Officer. Mr. Joyce has been with QualCare for more than 17 years and prior to his promotion was QualCare’s Vice President of Network and Delivery Systems. Annette Catino, Chief Executive Officer of QualCare noted that Kevin has been the key player in building QualCare’s network and shepherding new products to the marketplace. She went on to say that Kevin Joyce was among the first in the industry to recognize the shift to physician-owned outpatient surgery centers and pushed QualCare to advise its clients to
modify benefits to control costs. Ms. Catino suggested that it is this strategic vision as well as his relationships with New Jersey healthcare providers that make him a solid fit to serve as the Chief Operating Officer. The President of QualCare, Sharon Seitzman, agreed with Mrs. Catino, noting that QualCare’s network grew to more than 40,000 providers under Kevin’s direction and that his commitment to our Workers’ Compensation network helped clients achieve better market penetration. Kevin Joyce currently serves on the Board of Directors for the American Association of Preferred Provider Organizations (AAPPO) and on the Board of Directors for the NJ Chapter of Healthcare Financial Management Association (HFMA). Mr. Joyce graduated with a Bachelor of Science degree from York College.
On-Line Authorizations, Pre-Certifications and Referrals Going Live August 2016 Since January 1, 2012, QualCare has been a NaviNet partner and together we have been working to find ways to improve provider access to important data and streamline your experience. NaviNet allows providers access to crucial information in a user friendly and efficient manner including eligibility, benefits, claims status and explanation of payments (EOPs). By August 2016, you will also be able to submit authorizations, pre-certifications and referrals on-line using NaviNet. Using this system, your office will be able to get immediate responses and be informed if your request is pending or approved. Of course, you are always welcome to call our 800 number, but we believe that the efficiency of NaviNet will be an important time saver. If you have any questions regarding NaviNet or any other topic, please do not hesitate to call us at (800) 992-6613.
International Classification of Diseases, Tenth Revision (ICD-10) Update This article should serve as a reminder that, as of October 1, 2015, we no longer accept the older versions of the CMS 1500 claim form as they do not allow for ICD-10 codes or ICD indicators. The new, revised claim form — Version 02/12 OMB control number 0938-1197 — added the following functionality: • Indicators for differentiating between ICD-9 and ICD-10 diagnosis codes • Expansion of the number of possible diagnosis codes to 12
• Qualifiers to identify the following provider roles (on item 17): • Ordering • Referring • Supervising Any claim billed on an older CMS 1500 claim form will be returned to the submitter. The best and most effective way to ensure you are ICD- 10 compliant is to submit your claims electronically.
From the Doctor’s Office:
QualCare Medical Policy Update The updates listed below, summarize any changes to QualCare’s medical policies over the past six months. We have noted unchanged policies in cases where a specific service, device or procedure is remaining non-covered, after review of current published evidence. The full policies, including those indicated as new, are available on our website at www.qualcareinc.com located under the Provider tab. Actigraphy: Use as an alternative to polysomnography prior to multiple sleep latency testing is covered. Acute Inpatient Treatment for Eating Disorders: New policy Acute Inpatient Treatment for Substance Use Disorders: New policy Alternating Electric Field Therapy: New policy Bisphosphonates Injection: Additional covered indications of multiple myeloma and solid tumor skeletal metastases for ibadronate added. Initial authorization period increased from 6 months to one year. For organ transplant recipients, ICD codes denoting transplant status are accepted; as fracture codes are specific to cause. Bloodless Surgery: No changes. Bone-Anchored Hearing Aids: New coverage criteria as an alternative to CROS device. Unilateral and bilateral BAHA criteria specified separately. Breast Cancer Gene Expression Assay: Expanded coverage for ER+ tumors in postmenopausal individuals with one to three positive ipsilateral lymph nodes exclusive of micro-invasive lymph node disease.
BRCA Testing: Policy statement modified to encompass breast and ovarian cancer genetic susceptibility. When criteria specific to personal, family, or combined personal and family history are met, the covered CPT codes are 81211, 81214, 81216 - comprehensive BRCA1/2 analysis and BRCA large gene rearrangement (duplication/deletion) analysis for common variants. Coverage is not provided for screening in the general population without identified genetic risk. Colorectal Cancer Screening: Covered testing revised to include flexible sigmoidoscopy with or without interval stool testing; non-covered services list expanded to include serum markers and in vivo polyp analysis. Age and screening intervals are specified by risk category. Computed Tomographic Angiography: For acute chest pain evaluation with normal cardiac enzymes and EKG, included low pre-angiography probability of CAD as covered. Corneal Topography: No changes. Coronary Artery Calcium Scoring: No changes, remains investigational. Drug and Alcohol Detoxification: New policy. Endoscopic Treatment for GERD: Stretta device added to procedures addressed. No changes to statement, remains investigational. Electrical Stimulation Healing: No changes.
Extracorporeal Shock Wave Therapy: Podiatric/ orthopedic applications have no changes to statement, remains investigational. Facet Joint Injections and Denervation: Changed threshold from 50% relief to 75% relief for diagnostic medical branch block prior to considering a neuroablation procedure for facet pain. Bilateral injections are approvable when medical necessity is present. Other types of injections in the same region on the same day are not approvable.
First Trimester Screening for Genetic Abnormalities: Added statement defining high risk pregnancy for aneuploidy consisting of any of the following: maternal age ≥ 35 years, sonographic findings indicating an increased risk of aneuploidy, a prior pregnancy with a trisomy, and a parental balanced Robertsonian translocation with an increased risk of fetal trisomy 13 or 21. Prothrombin Time Home Monitoring: Removed criteria requirements of minimum twice a month testing and three months of prior anticoagulation.
Orthognathic Surgery: No changes. Partial Hospitalization for Eating Disorders: New policy. Partial Hospitalization Disorders: New policy.
Percutaneous Left Atrial Appendage Closure Procedures: New policy.
Hyperbaric Oxygen Therapy: Added the following
Positron Emission Tomography Scan: The covered oncologic indications include treatment planning.
conditions to those already covered: acute cyanide poisoning,
Pre-implantation Genetic Diagnosis: New policy.
after administration of antidote; central retinal artery occlusion; crush injury of the extremity with acute traumatic ischemia/vascular insufficiency; radiation-induced cystitis, with or without hemorrhage. Added the following conditions to those not covered: actinomycosis; idiopathic sudden sensorineural hearing loss; multiple sclerosis. Infertility-Diagnostic:
Beyond the definitions for
infertility earlier evaluation may be indicated based on medical history and physical findings. Several ICD codes for pelvic inflammatory conditions added. Coverage for the following testing in males added when criteria are met: 89331 sperm evaluation for retrograde ejaculation, urine; 51110 scrotal exploration; 88261/88262 karyotping, when nonobstructive azoospermia or severe oligospermia (<5million/ml count) is present; 88273 Y-chromosome microdeletion testing when non-obstructive azoospermia or severe oligospermia (<5million/ml count) is present. Removed blanket statement of non-coverage for pre-implantation genetic diagnosis. Infertility-Therapeutic: Added several ICD codes for pelvic inflammatory conditions. Removed blanket statement of non-coverage for pre-implantation genetic diagnosis. Influenza Vaccination: No changes to statement.
Residential Substance Treatment: New policy.
Selective Internal Radiation Therapy: Coverage added for unresectable intrahepatic cholangiocarcinoma. Single Photon Emission Tomography (SPECT): No changes.
Stereotactic Radiosurgery/Body Radiotherapy: No coverage added for medically or surgically inoperable stage I and II non-small cell lung cancer. Thyrogen: Use for TSH stimulated thyroglobulin measurement for differentiated thyroid cancer in lieu of thyroxine withdrawal; and as adjunctive to RAI for multinodular goiter is covered. Varicose Vein Interventions (Lower Extremities): Added the Varithena® procedure to those interventions considered investigational; delimited list of coverable varicose vein interventions. Please feel free to contact me directly at (732) 562-7802 with your comments and feedback on our medical policy content.
Intensive Outpatient Treatment for Substance Use Disorders: New policy. Intensive Outpatient treatment for Eating Disorders: New policy. New technology Assessment/New Policies: No changes; procedure section modified to reflect post-Cigna acquisition structure.
Michael McNeil, MD Medical Director
QualCare Providing New York City Employees Access to HMO Network Since 2002, QualCare and EmblemHealth have been doing business together via the QualCare PPO network which is offered to EmblemHealth Subscribers that reside in New Jersey, excluding City of New York Employees. We are pleased to announce that effective January 1, 2016, City of New York employees who reside in New Jersey will have the benefit option of utilizing the QualCare HMO network, where as previously to be covered at the in-network level of benefit, City of New York HMO members had to receive non-emergency care in New York. This new HMO offering will allow the City of New York employees, who reside in New Jersey, to obtain in-network care using their local community physicians and hospitals located in New Jersey. This effort is an expansion of the QualCare and EmblemHealth relationship and will not impact any members currently accessing the QualCare
Note when treating any member through EmblemHealth, the QualCare logo will appear on the member’s ID card and you can verify the member’s benefit coverage directly with EmblemHealth. Important contact numbers are listed on the member’s ID card. You can also visit www.emblemhealth.com/providers to access member information for eligibility, benefits and to review claims. For further questions regarding this information or your participation status in QualCare’s network, please contact our Provider Relations Department at 1-800-992-6613 ext. 7830. Thank you for your continued support.
One-of-a-Kind Workers’ Compensation Safety Group Paid Over $500,000 in Dividends to Its Participants in the Last Three Years QualCare and Advantage Specialty, our partner in workers’ compensation insurance, are pleased to announce that their joint Workers’ Compensation Safety Group for New Jersey health services providers has paid 50% in dividends on behalf of its participants since the group’s inception just three years ago. This workers’ compensation product is unique to the industry and available exclusively to physicians, dentists, chiropractors and pharmacies within New Jersey. David Scibal, CEO of Advantage Specialty noted that the safety group has performed extraordinarily well and that groups who received upfront credits of up to 20% off, have now received a 15% dividend in 2016. He went on to say that last year they paid a 10% dividend and 25% the year before, totaling 50% and almost $500,000.00 paid back to our members over three years.
Annette Catino, Chief Executive Officer of QualCare commented that the program was specifically designed for New Jersey physicians and pharmacies and is a way for QualCare to give back to our community of health service providers. She continued saying that participants who paid $10,000 in premiums received a $1,000 check. Launched in 2011, the Workers’ Compensation Safety Group was primarily produced by four New Jersey-based agents. Since then, a few additional agents have joined. The group’s creators continue to welcome additional brokers as long as they do not regionally compete with those agents who helped form the group. For information on how to participate in the Workers’ Compensation Safety Group, please contact David Scibal or Tom Basil, Jr. at (609) 365-8990 or via email [email protected]
Health Republic Insurance of New Jersey (HRINJ) Announces Physician Recognition Program Two years ago QualCare partnered with Health Republic
recognition program with a focus on behavioral risk factors.
The initial focus of the program is tobacco control. Smoking cessation counseling services can be provided at any office visit, regardless of the patient’s readiness to change. Many clinicians advise their patients to quit at every visit, but may fail to document the intervention, code and bill for it. Additional behavioral health recognition programs will be implemented over the course of the year.
There are four primary goals of the program:
The design of this physician recognition program is based on
Insurance of New Jersey (HRINJ), New Jersey’s first nonprofit, Consumer Operated and Oriented (CO-OP) health plan, to provide health care coverage to individuals and small groups. We are pleased to report that HRINJ’s Quality Improvement Committee recently approved a physician
1. Engage primary care physicians in the delivery of screening and preventive services for HRINJ members. 2. Foster strong links between primary care physicians and HRINJ. 3. Connect providers and their patients to HRINJ specialized services. 4. Measure the effectiveness of provider engagement and outreach on early detection of behavioral health needs. Early screening and engagement of health plan members for behavioral risk factors represent an important opportunity to develop interventions that improve access to care and lower future health care costs. A variety of screenings and preventive services can be performed by primary care physicians, including identification of tobacco use, screening for depression and screening for alcohol and substance abuse. Early identification of behavioral health problems is required under the Affordable Care Act. Those services, rated as A or B by the Preventive Services Task Force (PSTF), are to be provided to health plan members at no additional cost share. These services have been defined as “add on codes” in the AMA CPT manual. Most health plans and medical practices recognize these codes with additional fees or support their use through meaningful use of electronic medical records. In the current environment, these services are not consistently reimbursed. Some provider contracts reimburse, but the majority are bundled into the primary care or wellness encounter. Without the added reimbursement or recognition, physicians have no incentive to code these services when they are delivered.
claims data submitted in the preceding quarter. The ten physicians with the highest rates of smoking cessation counseling will be recognized and awarded a one hundred dollar honorarium. Physicians attaining recognition will be listed on NaviNet and HRINJ websites and receive a certificate of achievement. Data from claims will be used to identify smokers who may benefit from one or more of the enhanced smoking cessation services listed on our website at: https://newjersey.healthrepublic.us/smoking-cessation/. Details of the coding for smoking cessation is available on the NaviNet site on under medical polices at https://newjersey.healthrepublic.us/provider/. We welcome feedback on the design and implementation of this recognition plan. For comments and questions contact Edward Anselm, MD, HRINJ Medical Director at [email protected]
30 Knightsbridge Road Piscataway, NJ 08854
For more information visit us at www.qualcareinc.com For PPO questions contact 1.800.992.6613 For HMO and POS questions contact 1.800.254.0130 For Provider Relations contact 1.800.992.6613
QualCare’s Provider Manual and Clinical Practice Guidelines Are Available On-Line We are pleased to announce that QualCare’s Provider Manual is available online at www.qualcareinc.com under the Providers tab. Our manual offers you instructions on submitting claims, an explanation of members’ rights and responsibilities as well specific policy information. It also includes specific information about such topics as: utilization management; our quality improvement program; complex case management; our disease management program; and QualCare’s incentive statement. It is our goal to simplify your business operations by providing these materials in an on-line format so your office can access them as needed. We also have posted information about our Clinical Practice and Preventive Health Guidelines on-line. As with the Providers Manual, you can find all the guideline listed below along with many others at www.qualcareinc.com under the Providers tab: • Perinatal/Prenatal • Pediatric Wellness
• Asthma • Diabetes • Depression (Adult and Adolescent) • Post-Partum Depression QualCare has posted this information as part of our commitment to provide you with access to the latest clinical information and educational materials. The guidelines we have adopted are nationally recognized medical, behavioral health, and preventative health guidelines. They are used for our Quality Programs and are based on reasonable medical evidence. We conduct an annual review for content accuracy and update the guidelines to ensure they reflect current primary sources, new technological advances and recent medical research. If you have any questions about either the Provider Manual or the Clinical Practice Guidelines, please do not hesitate to reach out to us at (800) 992-6613. We are always interested in your feedback!
Provider Provider - Qualcare
InfoLine Health Plans That Care About Your Health Care
President’s Message QualCare’s acquisition by Cigna a year ago has led ...
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