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Provider Resources

May 2021

Table of Contents

Network Health Expanding Prior Authorization Programs with eviCore Healthcare
Virtual Practice Manager Meetings July 13 and 14
Delegate Reminder
CPT and HCPCS Code Updates
Quality Measures for Behavioral Health
Provider Data Validation
Provider Data Validation Using NPPES NPI Provider Data

Network Health Expanding Prior Authorization Programs with eviCore Healthcare

The new prior authorization programs being implemented include chiropractic services, physical & occupational therapy services (PT/OT) and gastroenterology services.

  • Beginning May 24, 2021, eviCore will begin accepting prior authorization requests for chiropractic services for Medicare members only for dates of service beginning on or after June 1, 2021.
  • Also beginning May 24, 2021, eviCore will begin accepting prior authorization requests for specialty therapy (PT/OT) for Medicare and Commercial members for dates of service beginning on or after June 1, 2021.
  • Beginning June 29, 2021, eviCore will begin accepting prior authorization requests for gastroenterology services (EGD, capsule endoscopy, colonoscopy) for Medicare and Commercial members for dates of service beginning on or after July 1, 2021.

eviCore’s Clinical Guidelines, CPT code lists, Frequently Asked Questions and request forms are available click here. Please keep in mind, services performed without authorization may not be reimbursed and you may not seek reimbursement from members.

The following orientation sessions have been designed to assist you and your staff with the new utilization management programs. These sessions will discuss the prior authorization requirements for therapy, chiropractic and gastroenterology services and how to navigate the eviCore portal. We encourage you to attend one of these sessions to ensure your understanding of the requirements and to promote your successful navigation of the eviCore authorization portal. Each online orientation session is free of charge and will last approximately one hour. All sessions are scheduled in Central Time.

  

Name of Session

Date

Time

Network Health Provider Orientation Training for Specialty Therapy (PT/OT)

June 2nd

10 a.m.

Network Health Provider Orientation Training for Chiropractic Services

June 4th

11 a.m.

Network Health Provider Orientation Training for Gastroenterology Services

June 22nd

11 a.m.

Network Health Provider Orientation Training for Gastroenterology Services

June 23rd

11 a.m.

Network Health Provider Orientation Training for Gastroenterology Services

June 28th

11 a.m.

Network Health Provider Orientation Training for Gastroenterology Services

July 1st

noon

 

How to Register:

All online orientation sessions require advance registration.

  1. Once you have selected a provider specific session, please go to http://eviCore.webex.com/
  2. Click on the menu bar on the far left hand side, then choose “Webex Training”
  3. Under Live Sessions, click the “Upcoming” tab, then enter the desired topic name exactly as below and search: Network Health Provider Orientation Training for Specialty Therapy or Network Health Provider Orientation Training for Chiropractic Services or Network Health Provider Orientation Training for Gastroenterology Services.
  4. Click “Register” next to the session(s) with the date and time you wish to attend
  5. Complete the registration information

An e-mail is sent to confirm registration. Please keep the registration e-mail as it will contain the toll-free phone number, meeting number, conference password, and a link to the web training session you have registered to attend.

If you have any questions regarding the eviCore web portal, please contact the Web Support team via email at portal.support@evicore.com or via phone at 800.646.0418 (Option 2). For any Client or Provider inquiries not associated with this training, please email ClientServices@evicore.com.



Virtual Practice Manager Meetings July 13 and 14

The practice manager meetings are scheduled for July 13 and July 14. The meetings will be virtual again and one hour in length from noon to 1:00 p.m. via Zoom.  Agenda details, speakers and sign up information will be sent in a separate email.

We understand that this is a busy time for you, so please make sure you look at the agenda and see if it pertains to your practice. 

We hope you are able to join us!



Delegate Reminder

For all delegates whom have been approved for Credentialing Delegation, please ensure you are notifying Network Health of an final resolutions of any inquires, investigations by regulatory agencies, or quality issues identified if the action will limit or restrict the provisions of services to our Members immediately upon receiving any communication or knowledge thereof. 

The following are conditions for reporting to Network Health.  (Please note these requirements are also listed in your provider contracts):  You may email NHPCredentialingdepartment@networkhealth.com with this information.

 Ancillary shall immediately notify Network of any material changes that will affect the availability or provision of Covered Services to Members under this Agreement, including, but not limited to:

(1) Any changes in the identity, reduction of employees, licensure status, accreditation, government and private certification, permits, medical staff privileges and/or professional capacity of Ancillary or any Provider, or any non-compliance with Network’s credentialing processes or procedures; quality issues, or an event which could reasonably impact the health and safety of our members needs to be reported to the credentialing department immediately; or

(2) Any disciplinary action of any type initiated against Ancillary or any Provider or any other health care professional associated with Ancillary or any Provider; or

(3) The unwillingness of Ancillary or any Provider to accept Members as new patients; or

(4) The transfer of all or substantially all of Ancillary’s assets.



CPT and HCPCS Code Updates

Quarterly, the American Medical Association updates Current Procedural Terminology (CPT) codes and the Centers for Medicare and Medicaid Services updates Healthcare Common Procedure Coding System (HCPCS) codes. 

There are new codes that will require prior authorization and these services fall within our current authorization, experimental and/or genetic review processes. You can find a list of all services requiring prior authorization on line at www.networkhealth.com.

If you have specific questions regarding a service, please contact our customer service or health management teams for assistance. For more information about authorization requirements, forms or services that require review under the experimental and/or genetic process visit the Provider Authorizations section of our website at www.networkhealth.com

Please forward this information to those within your facility who will need to follow these processes.  For prior authorization requests or questions, contact our care management departments Monday through Friday; 8 a.m. to 5 p.m.

Commercial: call 920- 720-1600 or 800-236-0208. For questions specific to behavioral health utilization, call 920-720-1340 or 800-555-3616. 

Medicare:  call 920-720-1602 or 866-709-0019  



Quality Measures for Behavioral Health

The Network Health quality management team works with providers and members to improve the continuity of care between medical and behavioral healthcare through six quality measures. Our quality team builds these measures based on factors and standards set by the National Committee for Quality Assurance (NCQA), using Health Effectiveness Data and Information Set (HEDIS) measures wherever applicable. Quality campaigns include collaboration with providers for data exchange and medical record reviews, as well as member communications encouraging follow-up visits and informational articles in member newsletters, magazines, blogs and social media.

The six measures addressed for behavioral health include the following areas that impact the health and well-being of members.

  • Exchange of Information
  • Follow-Up Care for Children Prescribed ADHD Medication
  • Antidepressant Medication Management
  • Follow-Up After Hospitalization for Mental Illness
  • Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
  • The Need for Depression Screening in Primary Care

 Exchange of Information (EOI) assesses the frequency that information is shared between primary care providers and behavioral health specialists regarding their mutual patients. Evidence of EOI is found through documentation in the primary care provider’s EMR. EOI assists providers in developing complete care plans, utilizing complimentary treatments, and avoiding undesired interactions and duplication of services.

Follow-Up Care for Children Prescribed ADHD Medication (ADD) assesses the percentage of members 6-12 years old who had at least three follow-up care visits within a 10-month period of initially starting an ADHD medication, or restarting after a period of 120 days with no ADHD medication being dispensed, mirroring best practice guidelines.

Antidepressant Medication Management (AMM) assesses the percentage of members 18 years and older who were prescribed an antidepressant for a diagnosis of major depression, and who continued taking the medication as prescribed. The goal of this measure is to identify barriers to medication compliance.

Follow-Up After Hospitalization for Mental Illness (FUH) assesses the percentage of members 6 years and older who were hospitalized for treatment of behavioral health diagnoses, and who had a follow-up visit with a mental health provider. Behavioral health specialists are uniquely qualified to identify treatment barriers or concerns for this population.

Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (SSD) assesses the percentage of members 18-64 years old who were dispensed an antipsychotic medication, and who had a diabetes screening test during the measurement year. Members in this population have a higher risk of diabetes and obesity, increasing the need for monitoring of metabolic effects.

The Need for Depression Screening in Primary Care assesses the percentage of members who indicated experiencing depression symptoms on the annual Health Risk Assessment (HRA), and who then received screening by their primary care provider. Primary care visits are often the first opportunity to identify depression related concerns.

For more information on how Network Health evaluates the quality of care and services provided to members visit https://networkhealth.com/provider-resources/quality-health-integration.

 

Network Health Behavioral Health Care Managers Support Patients in Need

If your patient has recently been discharged from an inpatient behavioral health unit, he or she should have a follow up appointment with a behavioral health provider within 7 days of discharge for optimum stability of symptoms.

Finding the right behavioral health provider for your patient can make all the difference in the counseling experience, and sometimes it can be challenging to find the right fit.

Does your patient need a psychiatrist for medication management, a psychologist for neuropsychological testing or a therapist for talk therapy? Would he or she prefer a male or female therapist? Does the therapist have special interest and training in the issue your patient wants to address?

Referring your patients to a Network Health care manager is like giving them a personal GPS to navigate the health care system, find providers, explore patients’ benefits and offer supportive phone calls between appointments. If patients agree, care managers will collaborate with their primary care doctors and specialists for optimum coordination of their care.

It is key for members to connect with the right providers for treatment plans that best serve members’ needs. The care managers stress to members the importance of follow-up appointments with their providers, encourage members to follow through with treatment plans, and help members find additional resources within the community.

Network Health care managers may be reached at: 920-720-1340 or 1-800-555-3616.


Provider Data Validation 

Network Health’s Provider Informatics Department is now required by CMS and NCQA to obtain quarterly updates on provider and/or facility data. In the past, you may have worked with an external company on behalf of Network Health.

As of February 15, 2021, Network Health has brought this process in-house. Due to this, someone from our Provider Informatics Department will be reaching out to your group quarterly to obtain information to confirm that the information we have is accurate.



Provider Data Validation Using NPPES NPI Provider Data

Network Health is asking providers to begin updating their NPPES provider data to help maintain the accuracy of their provider directories.

NPPES allows providers to attest to the accuracy of their NPI data. If a provider’s information is correct, they will be able to attest to it and NPPES will record and reflect the attestation date. If the provider’s information is not correct when they request any change to the NPI record, the provider will be able to attest to their changed NPI data, resulting in an updated certification date.

CMS will publish the latest certification date for each NPI in the NPI Registry as well as the NPPES dissemination file. Network Health will be using this data to aid us in the development of our provider directories, however, we can only use the most current data published, therefore, it would be imperative that you attest to the data regularly.  NPPES was recently updated to allow providers to input multiple addresses to support other work locations. 

Network Health will access core NPPES data weekly i.e., provider name, provider specialty, provider address, provider telephone number.  Collectively, these data elements represent 91% of the CMS provider directory review errors found. NPPES data will be compared to your provider data which is already being submitted and serve as an important resource to improve Network Health’s provider directory reliability and accuracy.

We encourage you to access the NPPES webpage at https://nppes.cms.hhs.gov today as well as quarterly to update and/or attest to your provider data.  It will be imperative to ensuring provider directory accuracy to our members.


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