February 2019

Featured Story: AllWays Health Partners Provider Resources

Access quick reference guides to support you with our transition to AllWays Health Partners.

In this Issue:

• Allways Health Partners Provider Resources
• HEDIS Data Collection
• Formulary Updates
• Annual Updates to Physician and Outpatient Reimbursement
• Medical Policy
• Contact Information

AllWays Health Partners Provider Resources

Provider Resources

We've created some quick reference guides to support you with our transition to AllWaysHealth Partners. Available resources include an FAQ, sample images of our new member ID card and information about our Partners HeatlhCare Plans. Please share these resources with your staff.

Claims

View a list of important medical and behavioral health claims submission information, such as payer IDs and mailing addresses. For the fastest processing time, remember to submit your claims electronically.

HEDIS Data Collection

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 2019 through the end of May 2019. 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.

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

For more information, view the HEDIS FAQ

Contact Us:

• Call: 857-282-7584
• Email: HEDIS@allwayshealth.org
• Fax: 617-526-1931

Formulary Upates

AllWays Health Partners regularly reviews and updates our formulary. Check out the latest updates effective April 1, 2019.

For the latest information on our pharmacy programs, visit our online formulary today!

Annual Updates to Physician and Outpatient Reimbursement

AllWays Health Partners reviews its physician and outpatient fee schedules quarterly to
ensure that they are current, comprehensive and consistent with industry standards, to the extent supported by its systems. In most cases, changes involve adding fees for new or existing codes to supplement the fees already on the fee schedule.

Consistent with prior years, AllWays Health Partners will update its Commercial/PPO physician, ambulance, drug, DME, laboratory, radiology and outpatient hospital fee schedules to incorporate new codes, effective January 1, 2019. Rate updates to existing CPT and HCPCS codes will occur on April 1, 2019.

With a few exceptions, AllWays Health Partners will continue to base fees on the Centers for Medicare & Medicaid Services (CMS) and MassHealth fee schedules, adjusted to achieve the contracted level of reimbursement

Commercial/PPO Physician Fee Schedules

• AllWays Health Partners will continue to base physician reimbursement on CMS RVUs and conversion factors
• AllWays Health Partners will continue to base drug, vaccine and toxoid reimbursement on CMS Part B levels, as indicated on the CMS Part B drug quarterly notices. If no CMS pricing is available, drug pricing will be set in relation to average wholesale price (AWP). Reimbursement for vaccines and toxoids will continue to be updated on a quarterly basis.

Commercial/PPO Outpatient Fee schedules

• Consistent with prior years, reimbursement will be based on a combination of ancillary and surgical fee schedules.
• AllWays Health Partners will continue to base drug, vaccine and toxoid reimbursement on CMS Part B levels, as indicated on the CMS Part B drug quarterly notices. If no CMS pricing is available, drug pricing will be set in relation to average wholesale price (AWP). Reimbursement for vaccines and toxoids will continue to be updated on a quarterly basis.

Medicaid Fee Schedules

• AllWays Health Partners will continue to base physician reimbursement on MassHealth published rates, where a published rate exists.
• Consistent with prior years, AllWays Health Partners will update its Medicaid physician, ambulance, drug, DME, laboratory, radiology and outpatient hospital fee schedules to incorporate new codes, effective January 1, 2019. Rate updates to existing CPT and HCPCS codes will occur within 30 days of receipt of notification of rate change from MassHealth.

If you have any questions about the fee schedule changes, please contact your AllWays Health Partners Provider Relations Manager.

Medical Policy

• Provenge - Annual review without substantial changes in medically necessary indicators.
• Kymriah - Annual review. Added introduction paragraph. Revised language under FDA-Approved indication section. Added DLBCL criteria. Added language under required documentation.
• Yescarta - Annual review. Added introduction paragraph. Edits made to FDAApproved indication section. Revised criteria and documentation sections.
• Lutathera - Annual review. Added criteria requiring the tumor has been shown to be somatostatin receptor-positive. Revised approval of duration. Removed reauthorization criteria.
• Home Prothrombin Time Monitoring Devices - Annual review without substantial changes in medically necessary indicators.

Click Here to view all medical policies.