Peach State Health Plan » News

Respiratory Syncytial Virus (RSV) Season

admin — Wed, 01 Sep 2010 16:40:29 +0000

Respiratory Syncytial Virus (RSV) Season

August 21, 2010

Dear Peach State Health Plan Clinician,

Please click the link below to review the Peach State Health Plan (Peach State) Synagis^®Authorization Guidelines for the 2010-2011 RSV season. These guidelines were developed based on recommendations of the American Academy of Pediatrics (AAP) and local Georgia physicians.

The following modifications have been made to the AAP guidelines for infants born between 32 weeks, 0 days through 34 weeks, 6 days:

Must be younger than 3 months of age at the start of the RSV season or born during the RSV season, and
Must either attend child care or have a sibling younger than 5 years of age.
If patient meets above criteria, Synagis should only be given until the infant reaches 3 months of age.

Peach State will again use Caremark as its preferred provider of Synagisfor the 2010-2011 RSV season. Beginning immediately, all requests for Synagis should be forwarded to Caremark for initial screening to determine if the request meets criteria for coverage. A copy of the Caremark RSV enrollment form can be obtained by clicking the appropriate link below or in the Pharmacy forms section of the website. When submitting the enrollment form, please attach the NICU discharge summary to expedite the review process.

Caremark will be responsible for the delivery of the injectable product and the overall coordination of the drug distribution process. All injectable products will be billed directly to Peach State by Caremark and shipped to your office. Administration charges for the injection should be billed directly to Peach State on a (HCFA) CMS 1500 claim form using CPT code 96372. You can also bill for an appropriate office visit for each administration of the drug.

Caremark specializes in specialty injectables and can provide the support and follow-up with Peach State members to ensure compliance and positive clinical outcomes. Caremark offers:

24-hour access to the Caremark case management team
Patient education and compliance monitoring programs
Direct refill and renewal coordination
Approved clinical protocols and treatment guidelines
Synagis approval for the entire RSV season

For RSV enrollment, please call 1-800-237-2767, or fax a completed Caremark RSV enrollment form prior authorization request form to 1-800-323-2445. For additional questions, contact the Peach State Pharmacy Department at 1-800-514-0083 option 2.

Thank you for your cooperation,

Dean Greeson, M.D.

Vice President, Medical Affairs

Enclosures:

Important Preferred Drug List (PDL) Updates

admin — Fri, 27 Aug 2010 17:57:30 +0000

Dear Peach State Provider:

Peach State Health Plan (Peach State) is making an important change to our Preferred Drug List. The change that will be made is described below:

Beginning October 1, 2010, Lexapro will be removed from the Peach State Preferred Drug List. Physicians must obtain prior authorization in order for a patient to receive Lexapro.

Antidepressants covered by the Peach State Preferred Drug List include Citalopram, Paroxetine, Fluoxetine, and Sertraline.

If you, as a physician, feel that your patient can not be treated with one of the antidepressant medications covered on the Peach State Preferred Drug List, you can submit a prior authorization request to US Script, the pharmacy benefit manager for Peach State Health Plan. The Medication Prior Authorization Request Form is available on the Peach State website, www.pshp.com, under the Provider Forms section. This form can be faxed to US Script at 1-866-399-0929.

Thank you,

Wendy D. Bailey, RPh. Robyn A. Lorys, Pharm. D.

Director of Pharmacy Director of Clinical Pharmacy

Peach State Health Plan Peach State Health Plan

Physician Summit Awards for Excellence In Care

admin — Thu, 19 Aug 2010 16:35:35 +0000

Contact: Debra Peterson-Smith

VP, Regulatory Affairs and Communications

PEACH STATE HEALTH PLAN ANNOUNCES

2010 PHYSICIAN SUMMIT AWARD

–OUTSTANDING PHYSICIANS AND PRACTIONERS FOR 2010–

Smyrna, GA (August 18, 2010) — Peach State Health Plan™ (Peach State), in collaboration with its parent company, Centene Corporation (NYSE: CNC), a national leader in healthcare solutions today announced the recipients of its 2010 Summit Awards for Excellence In Care. The Summit Awards are given each year to Physicians, Practitioners, and Obstetricians for providing clinical excellence. There are two award categories, one for Obstetrics, and one for Primary Care.

“Peach State is committed to recognizing Georgia providers for the excellent care they provide to our members,” said Patrick Healy, President, and Chief Executive Officer for Peach State. “We are pleased to recognize these providers in particular for their individual commitment to providing quality care and improving the health outcomes of our members.”

Dean Greeson, MD, Vice President, Medical Affairs for Peach State, stated, “It gives us great pleasure to award four deserving physicians in Georgia with this prestigious award.”

The Practitioners are selected for exemplary performance in several areas, including follow up after emergency room visits and routine preventive and well care services for adults and children.

Following are the 2010 Summit Award winners

(Primary Care)

Peach State Health Plan (Georgia)

-Renee Renfus, M.D.

- Josephine Dunagan, M.D.

-Aaron Goldberg, M.D.

“The OB category recognizes the extraordinary efforts in providing high quality obstetric care to all of our members,” explained Dr. Mary Mason, Senior Vice President and Chief Medical Officer for Centene. “Feedback from the members and their case managers helped determine the winners.” The individual criteria included risk-adjusted cesarean delivery rates, participation in the notification of pregnancy process and utilization of 17P, a weekly steroid injection to prevent premature birth in certain high risk women.

“The Society of Maternal Fetal Medicine supports activities that help elevate the level of quality and safety in obstetric care for the Medicaid patient,” added Dr. Daniel O’Keefe, Executive Vice-President, and Society for Maternal-Fetal Medicine.

The 2010 OB Summit Award winner

Peach State Health Plan (Georgia)

-Moon Chung, M.D.

About Peach State Health Plan

Peach State Health Plan (Peach State) is a Care Management Organization that serves the Medicaid and PeachCare for Kids ™ population in partnership with Georgia Families. Peach State is a wholly owned subsidiary of Centene Corporation, a leading multi-line healthcare enterprise offering both core Medicaid and specialty services. Information regarding Peach State is available via the Internet at www.pshp.com.

About Centene Corporation

Centene Corporation, a Fortune 500 company, is a leading multi-line healthcare enterprise that provides programs and related services to the rising number of under-insured and uninsured individuals. Many receive benefits provided under Medicaid, including the Children’s Health Insurance Program (CHIP), as well as Aged, Blind or Disabled (ABD), Foster Care and long-term care, in addition to other state-sponsored programs, and Medicare (Special Needs Plans). Centene’s CeltiCare subsidiary offers states unique “exchange-based” and other cost-effective coverage solutions for low-income populations. The Company operates local health plans and offers a range of health insurance solutions. It also contracts with other healthcare and commercial organizations to provide specialty services including behavioral health, life and health management, managed vision, telehealth services, and pharmacy benefits management. More information regarding Centene is available at www.centene.com.

Summer Provider Newsletter – Provider Report

admin — Mon, 16 Aug 2010 20:34:49 +0000

Please click the link below to read the summer issue of the Provider Report.

Provider Report – Summer 2010

Provider Watch – August 2010 – Timely Appointment Access Guidelines

admin — Mon, 16 Aug 2010 17:11:02 +0000

Please click the link below to review the Timely Appointment Access Guidelines.

Provider Watch – August 2010 (PDF)

National Drug Code (NDC) Requirement

admin — Thu, 12 Aug 2010 19:58:34 +0000

August 12, 2010

Dear Peach State Providers:

This letter serves as notice that effective September 12, 2010, Peach State Health Plan (Peach State) will begin requiring the inclusion of the National Drug Code (NDC) numbers on claim forms for all injectable drugs administered in the office or an outpatient setting. This requirement is consistent with Georgia Medicaid requirements, which states that providers are required to bill/report injectable drugs administered in offices and outpatient facilities using the manufacturer’s 11-digit NDC numbers. Claims for injectable drugs received for processing without the NDC numbers and/or corresponding HCPCS/CPT codes or with invalid numbers will be denied.

The 11-digit NDC number located on the drug vial that is used must be printed on the paper CMS 1500 form in field 24A above the date-of-service (DOS) or in field 44 if billing on the UB-04 form. The N4 qualifier preceding the NDC number is required for paper and electronic claim transactions, 837 (X12N). Failure to include the NDC code when submitting claims for injectable drugs will result in a claim denial.

Claim Examples of the CMS 1500 and UB-04 Forms below:

CMS 1500 Claim Form with required NDC for injectable drug – POS 11 (click image to enlarge)

CMS UB-04 Claim Form with required NDC for injectable drug – POS 22 (click image to enlarge)

If you have any questions about this notice, please contact Provider Services at 1-866-874-0633. Thank you for your continued participation with Peach State.

Sincerely,

Peach State Health Plan

Effective November 3, 2010 – Payment Policy – Labor Checks

admin — Thu, 05 Aug 2010 18:36:42 +0000

Dear Peach State Provider:

Effective November 3, 2010, Peach State Health Plan (Peach State) will implement a new payment policy to facilitate the payment of Labor Checks. A Labor Check is defined as evaluation of the fetal heart rate in labor using some form of fetal monitoring.

If the service is billed with one of the following ICD-9 Diagnosis Codes:

6441, 64410, 64413, 6440, 64400, 64403, 6442, 64420, 64421, 642, 6420, 64200, 64201, 64202, 64203, 64204, 6421, 64210, 64211, 64212, 64213, 64214, 6422, 64220, 64221, 64222, 64223, 64224, 6423, 64230, 64231, 64232, 64234, 6424, 64240, 64241, 64242, 64243, 64244, 6425, 64250, 64251, 64252, 64253, 64254, 6426, 64260, 64261, 64262, 64263, 64264, 6427, 64270, 64271, 64272, 64273, 64274, 6429, 64290, 64291, 64292, 64293, 64294, 641, 6410, 64100, 64101, 64103, 6411, 64110, 64111, 64113, 6412, 64120, 64121, 64123, 6413, 64130, 64131, 64133, 6418, 64180, 64181, 64183, 6419, 64190, 64191, 64193, 643, 6430, 64300, 64301, 64303, 6431, 64310, 64311, 64313, 6432, 64320, 64321, 64323, 6438, 64380, 64381, 64383, 6439, 64390, 64391 and 64393;

With one of the following Revenue Codes: 760, 761, 762, 769, 720, 721, 724, 729 and 450; And either Place of Service 23 (Emergency Room) or Place of Service 22 (Outpatient hospital).

Peach State will reimburse the Labor Check at a fixed encounter rate of $150.00 provided that proper prior notification has been given to Peach State.

Please contact your Provider Relations Representative at 1-866-874-0633 if you have questions regarding the notice.

Sincerely,

Kevin B. Sears

Vice President, Network Development

National Imaging Associates, Inc. (NIA) – Effective 08/02/2010

admin — Tue, 27 Jul 2010 22:55:16 +0000

Dear Provider:

As you know, Peach State Health Plan (Peach State) has partnered with National Imaging Associates, Inc. (NIA) to implement a radiology benefit management program. The high-tech radiology management program is on schedule to begin on August 2, 2010 for the following non-emergent outpatient radiology procedures:
• CT / CTA
• MRI / MRA
• PET Scan

Effective August 2, 2010, providers should contact NIA to obtain authorization for the services referenced above.

Peach State and the Georgia OB/GYN Association continue to work in partnership to address questions submitted by the Association’s member OB/GYNs regarding the implementation of the antepartum testing review program. Therefore, the implementation of the OB Ultrasound program will be delayed pending further communication from the health plan.

We appreciate your continued support and look forward to your assistance in assuring that Peach State members receive clinically appropriate advanced diagnostic imaging services. Should you have questions at this time, please contact your Provider Relations representative at 866-874-0633.

Sincerely,

Peach State Health Plan

Joint Communication with GA OB GYN Association

admin — Wed, 14 Jul 2010 13:01:29 +0000

Dear Peach State Provider:

Peach State Health Plan (Peach State) and the Georgia OB/GYN Association are working collaboratively in partnership to address the questions and concerns raised by the Association’s member OB/GYNs regarding Peach State’s proposed antepartum testing review program to be implemented by NIA. Our organizations will be meeting jointly on July 21st to discuss all outstanding issues. We are committed to working together to solve these issues in a mutually beneficial manner. As a first step, effective immediately, Peach State has agreed to no longer require “privileging” in order for Obstetricians to perform office based ultrasounds. All obstetricians who have already submitted an application will be automatically considered to have passed the privileging process. If you have not yet returned the application, you are not required to do so. Peach State and the Georgia OB/GYN society will work diligently to come to consensus on the details of the antepartum review program going forward, and we will update you when there are further details for distribution.

Thank you for your forbearance as we work through this process together.

Sincerely,

Peach State Health Plan

Human Papilloma Virus (HPV) Vaccine for Males

Peach State — Mon, 12 Jul 2010 14:58:40 +0000

Dear Peach State Provider:

The Advisory Committee on Immunization Practices (ACIP) now recommends the use of the quadrivalent HPV vaccine, Gardasil, for males, ages 9 to 21 years. Based on the ACIP recommendation and effective immediately, Peach State Health Plan will accept CPT code 90649 for females AND males, ages 9 to 21 years enrolled in the Georgia Medicaid and Peach Care for Kids programs.

The HPV vaccine will be supplied through the Vaccines for Children Program for males, ages 9 to 18 years, 11 months. The vaccine reimbursement is $8.00 for ages 9 to 18 years, 11 months. Males, ages 19 to 21 will be reimbursed according to the rate contained in your Peach State contract.

Providers should submit claims using the following billing guidelines:

CPT Code	Diagnosis Code	Modifier	Age Range
90649	V04.89 or V05.0038	EP	9 years – 18 years,11 mo
90649			19 years – 21 years

If you have any questions about this communication, please contact Peach State Provider Services at 1-866-874-0633. We will be happy to assist you.

Thank you.

Peach State Health Plan