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July 2019

Featured Story: AllWays Health Partners Switches to InterQual 2019

To align with the latest industry standards, AllWays Health Partners updates our criteria at least annually. InterQual updated their guidelines in May, and AllWays Health Partners will move to InterQual 2019 on August 26, 2019.

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AllWays Health Partners Switches to InterQual 2019

To align with the latest industry standards, AllWays Health Partners updates our criteria at least annually. InterQual updated their guidelines in May, and AllWays Health Partners will move to InterQual 2019 on August 26, 2019.

 

Inpatient Criteria

For the most part, there are no significant differences between the 2018 and 2019. However, there is a change to Observations in the Inpatient Criteria. For certain hospital services, hospitals must submit a prior authorization for an observation stay before an admission can be reviewed for medical necessity.

The services that require an observation stay can be loosely described as non-emergent, non-scheduled care, for example, when someone comes to the ED with chest pains or when someone is having a mild allergic reaction.

 

InterQual Criteria Lookup Tool

You can view the current criteria in the InterQual Criteria Lookup Tool on the provider portal. When we switch to version 2019, the new criteria will be available.

Remember to select the version you want to view in the search dropdown.

InterQual Criteria Tool-1

 


 

New Online Provider Directory Now Available

A new and improved provider directory is now available online. The latest updates make it easier for our members to find information on your practice and other providers in our networks.

Here are some of the improvements:

  • Filters to find specialists or facilities will be more prominent
  • Users can self-report corrections if they find any outdated or incorrect information, like a phone number or address (information gets fed to us immediately to review and submit changes)
  • New map feature to find providers more easily

Access our provider directory today at allwayhealthpartners.org.

Directory

 


 

Pharmacy Updates

AllWays Health Partners regularly reviews and updates our formulary to ensure alignment with the industry. Check out the latest updates effective September 1, 2019.

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

 



2018 EAPG Hospital Claims Reprocessing

During a recent review, we identified an update to the 2018 EAPG hospital claims processing for My Care Family members. As a result, we will reprocess some 2018 EAPG hospital claims and reimburse accordingly. You will see reprocessed claims on your July 3rd payment.



 

Medical Policy

The following medical policy updates are effective July 1, 2019:

  • Autologous Chondrocyte Implantation in the Knee
    • Revised language under Overview section to reflect policy only allows for MACI. Removed Carticel.
    • Revised Coverage guidelines. Allow for up to age 55. Removed requirement that member have inadequate response to prior surgical treatment.
    • Under Exclusion section; removed defects of the patella.
    • Updated Code and References
  • Dental Treatment Setting - Annual review. Under General Guidelines, added clarifying sentence regarding services performed in dental offices. References updated.
  • Hearing Devices - Annual review. References updated.
  • Speech Generating Devices - Annual review. References updated.

Click Here to view all medical policies.

 


 

Thank You From The HEDIS Team

The HEDIS team at AllWays Health Partners would like to thank each of our providers for their prompt response fulfilling medical records and additional information requests. The HEDIS review period is time sensitive, and we appreciate all assistance in our data collection efforts.

 


 

Hospital Inpatient Utilization Report

The latest quarterly hospital inpatient utilization report is now available. To review this report, click on the Reports tab in the Provider Portal and select Clinical Reports. If you do not have access to the Provider Portal, you may register online at allwaysprovider.org.




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