Peach State Health Plan » News

Important Changes to Peach State’s Preferred Drug List (PDL) – Effective April 1, 2010

Lasha Moore — Tue, 02 Mar 2010 21:47:22 +0000

Dear Peach State Provider:

Peach State Health Plan (Peach State) is making some important changes to our Preferred Drug List, beginning April 1, 2010. The changes that will be made are described below:

Patients will only be allowed to receive one long acting stimulant and two short acting stimulants per month without prior authorization.
The refill threshold for controlled substances, such as narcotic analgesics, benzodiazepines, stimulants, and amphetamines, will be changed from 85% to 90%.

If you, as a physician, feel that a patient will require medication therapy outside of the above guidelines, 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

Provider Secure Portal – Office Manager Tool (new web enhancement)

Peach State — Tue, 02 Mar 2010 16:05:39 +0000

Great News!! Peach State is proud to announce a new web enhancement to the Provider Secure Portal. An Office Manager function has been added. This role allows a user who is designated as the Office Manager during the Secure Portal registration process to manage the other users associated with the Provider’s Tax Id Number.

The user designated as the Office Manager will have the ability to create new user logins, disable user logins, and reset passwords for other office staff associated with the same TIN. At least one user for the provider site should be designated as Office Manager.

Provider offices that have not previously designated an Office Manager during the registration process must create one by registering at www.PSHP.com. During the registration process, please select the Office Manager Role.

Provider offices in which multiple users have been designated as the Office Manager during registration, we recommend that you review the users registered for your TIN and adjust the roles of any user flagged incorrectly as Office Manager.

Peach State will be offering Webinar sessions to demonstrate the functions available with this new Office Manager Role. The webinar sessions will be offered March 8, 2010 through March 12, 2010 at 12:00 PM and 2:00 PM. Please register for these sessions by accessing https:centene.webex.com. Click on the Meeting Center tab and then Browse the Meetings available on the Monthly tab to register for one of the Peach State Secure Portal Office Manager Training sessions.

Hospital Statistical Reports (HS&R)

Peach State — Mon, 01 Mar 2010 22:12:22 +0000

Requests for Hospital Statistical Reports (HS&R)

Dear Georgia Hospital Provider:

Peach State Health Plan (Peach State) is pleased to announce a new and more efficient process for responding to your requests for HS&R reports. The new process allows Peach State to track report request through a single entry point and increase the turnaround time for production and delivery of your reports. We will also provide you with an acknowledgement notice that confirms the receipt and processing of your request.

Effective immediately, you must adhere to the process outlined below when requesting HS&R reports.

All requests for production of HS&R reports must be submitted via e-mail to the designated e-mail box or via certified mail to the address identified below.
Please note: Any request submitted directly to an individual’s attention will be returned to the requestor via email with instructions on how to submit the request via one of the methods identified below.
Acknowledgement notices will be provided via email within three (3) calendars days of receipt of your email request.
Acknowledgement notices will be provided in writing within five (5) calendar days of your written request.
Submit your e-mail request to:
- HSRRequest@pshp.com
- SUBJECT: Request for HS&R Report

Submit your written request via Certified mail to:

Peach State Health Plan
VP of Compliance
3200 Highlands Parkway SE
Suite 300
Smyrna, GA 30082
ATTN: Request for HS&R Report

Reminder:

In order to generate your reports, you must provide the following information:

a. Hospital Name
b. Hospital Tax ID Number
c. Provider Medicaid ID Number
d. Hospital fiscal year or period service dates
e. Hospital fiscal year or period for paid through dates
f. Contact Information – including email

Post Processing Claims Audit

admin — Mon, 01 Mar 2010 17:47:54 +0000

Background

Peach State Health Plan (Peach State) is contractually obligated to have procedures in place to detect waste, fraud, and abuse. This is achieved through:

Claims editing
Post-processing review of claims
Provider profiling and credentialing
Quality control
Utilization management

As accountable and fiscally responsible stewards of public funds, we take the prevention and detection of waste, fraud, and abuse very seriously. Peach State has a management contract with its parent organization, Centene Corporation (Centene) in which Centene conducts routine post-processing claims audits on behalf of Peach State. These audits are designed to ensure that billing codes and practices are correct and that Peach State has paid health care providers appropriately. In addition to provider reviews, Centene also investigates members who appear to be abusing the Medicaid and PeachCare for Kids programs.

Post Processing Claims Audit

A post-processing claims audit consists of a review of clinical documentation and claims submissions to determine whether the payment made was consistent with the services rendered. To start the audit, Centene Auditors request medical records for a defined review period. Providers have two weeks to respond to the request; if no response is received, a second and final request for medical records is forwarded to the provider. If the provider fails to respond to the second and final request for medical records, or if services for which claims have been paid are not documented in the medical record, Peach State will recover all amounts paid for the services in question.

Centene Auditors review cases for potential unbundling, upcoding, mutually exclusive procedures, incorrect procedures and/or diagnosis for member’s age, duplicates, incorrect modifier usage, and other billing irregularities. They consider state and federal laws and regulations, provider contracts, billing histories, and fee schedules in making determinations of claims payment appropriateness. If necessary, a clinician of like specialty may also review specific cases to determine if billing is appropriate. Auditors issue an audit results letter to each provider upon completion of the audit, which includes a claims report which identifies all records reviewed during the audit. If the Auditor determines that clinical documentation does not support the claims payment in some or all circumstances, Peach State will seek recovery of all overpayments.

Depending on the number of services provided during the review period, Peach State may calculate the overpayment using an extrapolation methodology. Extrapolation is the use of statistical sampling to calculate and project overpayment amounts. It is used by Medicare Program Safeguard Contractors, CMS Recovery Audit Contractors, and Medicaid Fraud Control Units in calculating overpayments, and is recommended by the OIG in its Provider Self-Disclosure Protocol (63 Fed. Reg. 58,399; Oct. 30, 1998). To ensure accurate application of the extrapolated methodology, Centene uses RAT-STATS 2007 Version 2, the OIG’s statistical software tool, to select random samples, assist in evaluating audit results, and calculate projected overpayments.

Providers who contest the overpayment methodology or wish to calculate an exact overpayment figure may request a full, on-site chart audit of all services rendered during the review period. A full chart audit may take four to eight weeks to complete. On-site audits are performed by Peach State’s contracted vendor, HMS. Per the terms of your contract, you may be liable for the cost of an on-site audit.

Audit findings are reported to the Department of Community Health and may also be reported to the Georgia Healthcare Fraud Control Unit.

Additional information regarding Peach State’s Waste, Fraud, and Abuse program may be found in the Provider Manual. To report wasteful, abusive, or fraudulent activity, please contact Peach State’s Confidential Hotline at 1-866-685-8664.

CENTENE FOUNDATION – AWARDS GRANT TO FRAGILE KIDS FOUNDATION

Peach State — Fri, 12 Feb 2010 16:54:54 +0000

N E W S R E L E A S E

Media Contact: Deanne Lane

Senior Director, Media Affairs

(314) 725-4477

WASHINGTON, D.C. (February 11, 2010) — The Centene Foundation for Quality Healthcare announced today that it has awarded a $35,000 grant to Fragile Kids Foundation, Inc. (FKF), a nonprofit organization based in Atlanta, Ga. The grant award will launch the Fragile Kids Partner Program, an effort to better reach underserved, rural Georgia families caring for medically fragile children with a range of diagnoses, including cerebral palsy, spina bifida, muscular dystrophy, mitochondrial disorder and other genetic/trauma disorders. The goal of the program is to provide medical equipment and therapy tools to those children in Georgia who are not covered by insurance or any other healthcare option by collaborating with partners in the state that are established social, educational and therapy “homes.”

“For many medically fragile children, durable medical products represent the sort of crucial equipment needed for them to grow and thrive,” said Kathy Bradley-Wells, President, Centene Foundation for Quality Healthcare. “The Fragile Kids Partners Program strengthens FKF’s capacity to serve children and families who experience healthcare disparities throughout Georgia.

“In a grassroots effort to reach out to rural caregivers of special-needs and chronically ill children, we learned that we share so many of the same families in our equipment grants program with other smaller organizations,” said Carolyn Polakowski, Executive Director, Fragile Kids Foundation. “We discovered that these small, struggling community resource initiatives rarely have the appropriate medical equipment for children in attendance to share. Joining forces with these smaller partners is a natural progression of our mission to fill the gaps for all children with a medically fragile diagnosis. This grant from the Centene Foundation will empower us to launch the program statewide and deepen our network of community advocates and therapists.”

About Fragile Kids Foundation, Inc.

The Fragile Kids Foundation, a twenty-year-old charitable organization serving the entire state of Georgia, provides medical equipment and durable medical goods to medically fragile children that are not covered by government (Medicaid) or private insurance programs. 76% of the children benefitting from the programs of FKF have incomes hovering at the poverty line; 50% of the children are cared for by single mothers and grandmothers. The Foundation provides wheelchair lifts, specialized car seats, communication aids, toileting and bathing systems and other prescribed equipment for children that cannot be secured through other means. Children from birth to 21 who reside in Georgia and have a medically fragile diagnosis—Cerebral Palsy, Spina Bifida, Muscular Dystrophy, Mitochondrial disorder and other genetic and traumatic disorders are eligible for support. The Foundation provides equipment through the “Healthcare Grants” and “Loaned Equipment programs.” The new Partners Program sponsored by Centene Foundation will launch in 2010. For additional information, please visit www.fragilekids.org.

About The Centene Foundation for Quality Healthcare

The Centene Foundation for Quality Healthcare is a non-profit private foundation dedicated to improving the quality of healthcare in the United States. The Foundation serves as a resource to identify and support innovative approaches to improving and increasing the quality of and access to healthcare for low-income individuals and families. This is accomplished through an inspired philanthropic giving plan that seeks to promote efforts and activities that identify and address core causes of unequal access and treatment in healthcare. For additional information, please visit www.centenefoundation.org.

Important Changes to Peach State’s Preferred Drug List (PDL) – Effective March 1, 2010

Peach State — Wed, 20 Jan 2010 22:59:21 +0000

January 20, 2010

Dear Peach State Provider:

Peach State Health Plan (Peach State) is making some important changes to our Preferred Drug List, and we are writing to communicate the changes to you. Beginning March 1, 2010, the changes described below will be made.

Patients receiving a new prescription for an atypical antipsychotic will be required to try generic risperidone prior to taking a branded drug in the same class. Patients already on therapy with a branded atypical antipsychotic will be allowed to remain on the current therapy, but will be required to try risperidone if a change in medication is needed.
Focalin and Focalin XR will no longer be preferred drugs on the Peach State Preferred Drug List. Patients already receiving Focalin and/or Focalin XR will be allowed to remain on the current therapy, but all new starts with Focalin or Focalin XR will require prior authorization.

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

Provider Secure Web Portal Maintenance

Peach State — Fri, 18 Dec 2009 22:22:03 +0000

Our eligibility and claims systems will be unavailable on Saturday, Dec. 19 for scheduled maintenance. Please try back later to complete your transaction. Thank you.

Hospital Statistical Reports (HS&R) Requests

Peach State — Thu, 10 Dec 2009 19:33:25 +0000

Requests for Hospital Statistical Reports (HS&R)

Dear Georgia Hospital Provider:

Effective immediately, you must adhere to the process outlined below when requesting HS&R reports.

All requests for production of HS&R reports must be submitted via e-mail to the designated e-mail box or via certified mail to the address identified below.
Please note: Any request submitted directly to an individual’s attention will be returned to the requestor via email with instructions on how to submit the request via one of the methods identified below.
Acknowledgement notices will be provided via email within three (3) calendars days of receipt of your email request.
Acknowledgement notices will be provided in writing within five (5) calendar days of your written request.
Submit your e-mail request to:
- HSRRequest@pshp.com
- SUBJECT: Request for HS&R Report

Submit your written request via Certified mail to:

Peach State Health Plan
VP of Compliance
3200 Highlands Parkway SE
Suite 300
Smyrna, GA 30082
ATTN: Request for HS&R Report

Reminder:

In order to generate your reports, you must provide the following information:

American Medical Association 2009 H1N1 Influenza Information for Physicians

admin — Thu, 03 Dec 2009 12:03:56 +0000

The American Medical Association (AMA) web site offers up to date and practical information for helping patients during the 2009-2010 seasonal flu season and clinical guidelines to manage the 2009 H1N1 influenza virus. Please review the link below to access the latest developments and information regarding H1N1 influenza virus.

AMA web site

H1N1 FAQs

admin — Tue, 01 Dec 2009 20:10:04 +0000

Frequently asked questions on use of influenza A(H1N1) 2009 monovalent vaccines (2009 H1N1 monovalent influenza vaccines): Practical considerations for immunization programs and providers

Two different influenza vaccines are available this influenza season, and many people will be recommended to receive both the seasonal influenza vaccine and the 2009 influenza A (H1N1) 2009 monovalent vaccine (referred to in this document as 2009 H1N1 monovalent influenza vaccine). Below are some practical considerations for use of influenza vaccines. This information is only intended to address the current flu season and might change as the situation unfolds. This information is not intended to be applied to routine use during future seasonal influenza vaccination efforts.

1. Children ages 6 months through 8 years receiving seasonal influenza vaccination for the first time are recommended to receive 2 doses. However, in the prescribing information (package inserts) for 2009 H1N1 monovalent influenza vaccines, children ages 6 months through 9 years are recommended to receive 2 doses. Does CDC recommend that clinicians follow the recommendation in the 2009 H1N1 monovalent vaccine package inserts or use the standard seasonal vaccine recommendations?

The recommendations for use of seasonal vaccine are unchanged – children 6 months through 8 years receiving seasonal influenza for the first time are recommended to receive 2 doses. Other children just need one dose of seasonal influenza vaccine.
Using the 2009 H1N1 monovalent influenza vaccine schedule presented in the prescribing information is recommended (6 months through 9 years receive 2 doses regardless of earlier vaccination with seasonal influenza vaccine).

2. The interval between doses stated in the 2009 H1N1 monovalent influenza vaccine prescribing information is “approximately 1 month”. What does “approximately 1 month” mean?

CDC recommends that the two doses of 2009 H1N1 monovalent vaccines be separated by 28 days (4 weeks).

3. The 2009 H1N1 monovalent influenza vaccine trials that are currently underway have often used a 21 day (3 week) interval between doses. Is a 21 day interval acceptable for inactivated 2009 H1N1 monovalent vaccines?

CDC recommends that the two doses of 2009 H1N1 monovalent influenza vaccines be separated by 28 or more days (4 weeks). However, trials of the inactivated 2009 H1N1 vaccines have often used a 21 day interval. Administering the two doses of a 2009 H1N1 monovalent inactivated influenza vaccine at least 21 days apart is safe and acceptable. Therefore, if the second dose of an inactivated 2009 H1N1 monovalent vaccine is separated from the first dose by at least 21 days, the second dose can be considered valid. If the interval separating the doses is less than 21 days, the second dose should be repeated 28 or more days after the invalid (second) dose (≥ 21 days is acceptable for this interval also).

4. Can the seasonal inactivated vaccine (trivalent inactivated vaccine or TIV) and the 2009 H1N1 monovalent inactivated vaccine be given at the same visit?

Yes.

5. If seasonal LAIV and 2009 H1N1 monovalent LAIV are inadvertently given at the same visit, do either or both doses need to be repeated, and if so, when?

Seasonal LAIV and 2009 H1N1 monovalent LAIV should not be administered at the same visit. While use of the 2 types of LAIV at the same visit could result in reduced immunogenicity for one vaccine, according to some experts, there are no data describing what happens with the vaccine response following simultaneous administration of LAIV vaccines. However, if both types of LAIV are inadvertently administered at the same visit neither vaccine, needs to be repeated.

6. What is the minimum interval between doses of seasonal LAIV and 2009 H1N1 monovalent LAIV?

There are no data on sequential administration of seasonal and 2009 H1N1 monovalent LAIV. The ACIP recommends a minimum interval of 28 days (4 weeks) between use of a seasonal LAIV and a 2009 H1N1 monovalent LAIV because these are considered to be 2 different vaccines. The ACIP recommendations were developed based on data from studies using attenuated injectable live virus vaccines such as the measles, mumps and rubella vaccine. Trials of 2009 H1N1 live attenuated vaccines have used a 28 day interval between doses and therefore, 28 days is the recommended interval between 2 doses of LAIV (seasonal and H1N1 monovalent LAIV). However, based on previous studies of LAIV replication and immune response, as little as 14 days (2 weeks) might be sufficient to allow for an appropriate immune response to both vaccines. Therefore, an interval between the two types of LAIV of 2 weeks or more may be acceptable, although an interval of 28 days is preferred.

7. If seasonal LAIV and 2009 H1N1 monovalent LAIV are not administered on the same day, but are separated by less than 14 days (2 weeks), do either or both doses need to be repeated, and if so, when?

Seasonal LAIV and 2009 H1N1 monovalent LAIV should not be administered at the same visit, and should be separated by at least 28 days (14 days acceptable based on previous studies of attenuated influenza vaccine virus replication and immune response). If accidentally given at the same visit, neither dose needs to be repeated. If given 1-13 days apart, the second dose should be repeated 28 days (14 days acceptable) from the invalid (second) dose.

8. Can a live attenuated vaccine be given at the same visit as an inactivated influenza vaccine (e.g., seasonal LAIV and 2009 H1N1 monovalent inactivated vaccine, or 2009 H1N1 monovalent LAIV and seasonal trivalent inactivated influenza vaccine [TIV])?

Yes, based upon ACIP’s recommendations, these two types of vaccines can be given at the same visit.

9. Can a child who requires 2 doses of a 2009 H1N1 monovalent influenza vaccine and who received the first dose with an inactivated 2009 H1N1 monovalent vaccine complete the series with the 2009 H1N1 monovalent LAIV, or vice versa?

There are limited data describing the immune response to mixed schedules. Therefore, when feasible, the same type of vaccine (live attenuated or inactivated) should be used in a two-dose schedule. Mixed schedules however, are preferable to not completing the series. A 28 day interval between doses is recommended, but 21 days is acceptable. If vaccines are separated by 1-20 days, repeat the invalid (second) dose 28 days (21 days acceptable) from the invalid second dose.

10. Should we set aside doses of 2009 H1N1 monovalent vaccine to administer as second doses to children 6 months through 9 years?

No. 2009 H1N1 monovalent influenza vaccine availability is expected to increase during the next several weeks, so vaccine should not be held in reserve for patients who already have received 1 dose but might require a second dose.

Source: http://www.cdc.gov/H1N1flu/vaccination/top10_faq.htm