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December 2020

Featured Story: 2021 products and member ID cards

Get a look at our 2021 product portfolio and the member ID cards your patients will be bringing to their upcoming appointments

In This Issue

 


 

2021 products and member ID cards 

Get a look at our 2021 product portfolio and the member ID cards your patients will be bringing to their upcoming appointments. 

Here are some highlights of what to expect:

Select HMO will launch on January 1

In 2021, AllWays Health Partners will launch a new high-performance network product that will have access to the Select HMO network. This product will be available through the MA Health Connector, including to ConnectorCare members. 

UPDATED: Mass General Brigham employee plan ID cards

Don't forget to check out our updated Mass General Brigham employee plan ID cards with the new Mass General Brigham logo. 

Allies HMO continues to grow

Allies, a brand new health plan product in partnership with Newton-Wellesley Hospital, is now available to large groups in the service area. Allies members have access to unique features including: a dedicated health navigator, quicker appointment times for select specialties and enhanced virtual care.

PPO Plus members will have access to the United Healthcare Options PPO network 

Beginning January 1, PPO Plus members will have in-network access to the AllWays Health Partners network within our MA/NH service area plus access to the United Healthcare Options PPO network when outside our MA/NH service area.

2021 Products

 


 

Getting instant outpatient prior authorization approvals with InterQual Connect 

Now when you submit prior authorization for outpatient services you can get an approval in seconds through InterQual Connect. Here are 3 things to know before you submit your prior authorization request:

1. Complete the Q&A to determine medical necessity

When initiating a new request, you will be prompted to select the appropriate criteria subset and answer a series of simple, rules-driven questions to determine medical necessity. If the service meets medical necessity, you will receive an approval. Check out our quick reference guide for screenshots and step-by-step instructions.

2. If the authorization pends, requests with a completed Q&A section will be prioritized for review

If medical necessity cannot be determined based on your answers, please upload clinical information so we can prioritize your request. Your request will take longer to review if you skip the Q&A section or do not answer all the questions presented.

3. Have the patient's medical chart available when initiating a request

To help answer the questions, remember to have the patient's medical chart available when you are ready to submit the request. Please answer the questions appropriately based on the medical chart. As a reminder, all prior authorizations are subject to backend auditing.  

Visit our Prior Authorization page to get more information and resources about InterQual Connect. 

 


Survey: Annual provider satisfaction survey

Each year, AllWays Health Partners conducts a satisfaction survey to better understand the provider experience. More than ever, your feedback is useful to help us identify ways we can make things easier for you and your staff through the pandemic and beyond. 

Please take a few moments to take our 2020 survey. We thank you in advance, and appreciate your time and honest feedback. 

Take the survey

 


 

COVID-19 updates

As of January 1, 2021, we will remove cost sharing (copayments, deductibles, or coinsurance) for telemedicine services only for medically necessary COVID-19-related visits. Cost sharing will resume for other telemedicine visits with PCPs, specialists, and additional providers, such as urgent and routine care, and outpatient behavioral health services. 

Check out our COVID-19 FAQs for the latest updates

Our COVID-19 FAQs for providers give you the latest information, updates and resources. We are constantly updating these FAQs as more information becomes available from the Federal and State governments. Please check back periodically to get the most recent news.

Read the COVID-19 FAQ for Commercial providers

Read the COVID-19 FAQ for My Care Family providers

 
 

 

HEDIS data collection starts in January

The Healthcare Effectiveness Data and Information Set (HEDIS®) is a widely-used standardized set of performance measures developed and maintained by the National Committee for Quality Assurance (NCQA). HEDIS was designed to help consumers compare health plan performance to other plans and to national or regional benchmarks.

Each year, NCQA requires health plans to collect and report HEDIS data from contracted providers. HEDIS data collection will run from January 2021 through April 2021. A member of AllWays Health Partners' HEDIS staff will ask you to fax, mail, submit by FTP the information or schedule an onsite review at your location.

Based on the HEDIS measures, PCPs and a subset of specialties such as OB/GYN, cardiology, ophthalmology, and optometry are the most likely to receive a medical records request.

Accessing medical records

To help simplify the process, please provide the contact information of the staff who manages access to your organization's medical records as well as the best way for us to contact them.

We appreciate your cooperation and timely response during this review and thank you in advance.

For more information, view the HEDIS FAQ

Medical Record contact info

 


 

Medical policy

The following medical policy updates are effective December 1, 2020:

  • Artificial Pancreas Device System - Annual review. References updated.
  • Vitamin D Screening and Testing - Annual review. References updated.
  • Macrilen - Annual review.

The following medical policy update is effective February 1, 2021:

  • Out of Network Providers - Off-cycle review. Changes made to add additional regulation and defined affected membership. 

View all medical policies.

 


 

Code updates

Stay current on the latest code and reimbursement updates.

Check out the latest updates here.

 


 

Reminder: Confirm your Provider Directory information

To ensure that your patients and prospective patients have access to the correct information for your practice, it is important to regularly validate your practice information in our Provider Directory and let us know when an update is needed.

Remember to review information such as: contact information (telephone, fax, email), addresses, website information, network participation status, availability to see new patients, and which individual providers work at each practice location.

You can submit a provider information update request 24/7 through our secure Provider Portal or by submitting the Standardized Provider Information Change Form to pec@allwayshealth.org.

 


 

Available resources 

Our website provides you with important resources and information to support you and your staff. Here's a sample of what's available:

Clinical Resources:

  • Medical Policies - Medical policies provide you with the coverage criteria for specified conditions. You can find more information on the utilization management (UM) decision making process and how to obtain UM criteria in the Provider Manual.
  • Clinical Contact Information - Clinical staff is available at 855-444-4647 Monday-Friday (8:30 AM - 5:00 PM). After hour coverage is available after 5 PM on weekdays and on the weekends.
  • Case Management Programs - You can get more information on specific programs and how you can refer a member into one of our case management programs. Providers can refer by emailing caremanagement@allwayshealth.org
  • Tobacco Cessation - For members who are trying to quit tobacco, we offer a tobacco cessation program run by our Certified Tobacco Treatment Specialists. Providers can refer by email: quitsmoking@allwayshealth.org
  • Health Coaching - Health coaching is available for members trying to improve eating habits, increase their physical activity, manage weight and decrease stress. Our health coaches have all completed the rigorous Wellcoaches® school of coaching training program. Providers can refer by emailing: healthandwellness@allwayshealth.org

Provider Manual

The Provider Manual includes important information on how you can support your patient. Topics in the Provider Manual include:

  • Quality Improvement Program
  • Utilization Management Decision-Making - This includes information regarding our decision-making process and procedures. We do not specifically reward practitioners or other individuals conducting utilization review for issuing denials of coverage or service, nor do we provide financial incentives to UM decision-makers to encourage decisions that result in under-utilization.
  • Credentialing and Re-credentialing Processes
  • Member Rights & Responsibilities
  • Practitioner Rights & Responsibilities
  • Interpreter Services

Pharmacy Benefit Program

Our website gives you the most up-to-date information about our Pharmacy programs, covered medications and the current medical necessity criteria. Pharmacy programs include:

  • Excluded Medication - A medication which is considered to be excluded from the pharmacy benefit.
  • Pharmacy & Therapeutics Committee - This Committee is chaired by the Medical Director responsible for pharmacy and is composed of practicing pharmacists and practicing providers with varying specialties, including behavioral health, internal medicine and pediatrics. It meets regularly throughout the year, no less frequently than quarterly.
  • Prior Authorization - A pharmacy program which limits access to a medication by establishing criteria for appropriate use of a medication. These criteria must be met and documentation sent to us before the medication will be covered. Prior authorization is also required for exception to our mandatory generic medication pharmacy benefit.
  • Quantity Limit - A pharmacy program that limits the number of units per time period for a specific medication based on recommended doses.
  • Step Therapy - A pharmacy program which allows patients who meet criteria to have coverage for their prescription adjudicate without review based on available medication history.
  • Mandatory Generic - A pharmacy program which requires a trial of an FDA approved generic substitution for a brand name medication, if it is available.
  • Tier Placement - A pharmacy program that places medications in one of six co-payment tiers for benefit plans with a six-tier pharmacy benefit.
  • Therapeutic Interchange/Substitution - A pharmacy program that involves the dispensing of a chemically different drug, considered therapeutically equivalent, i.e., will achieve the same outcome, in place of a drug originally prescribed by a physician. The drugs are not generically equivalent. Therapeutic substitutions are done in accordance with procedures and protocols set up and approved by physicians in advance. Therefore, the pharmacist would not have to seek the prescribing physician's approval for each interchange.

Visit our webpage.




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