Provider Resources

November 2019

Table of Contents

Network Health Celebrates American Diabetes Month in November with a Focus on "Prevention"
Diagnosing Diabetic Retinopathy
New $25 Insulin Program for Commercial Members
2020 Annual Pharmacy Notification
Network Health Holidays


Network Health Celebrates American Diabetes Month in November with a Focus on "Prevention"

Network Health focuses both on the prevention of diabetes and effective management of diabetes. This year, we launched an innovative diabetes prevention program with our Medicare members and it has been very successful. This program focuses on patients with a diagnosis of prediabetes. The Centers for Medicare & Medicaid Services (CMS) research shows that prediabetics may decrease their risk of transitioning to a diagnosis of Type 2 diabetes by 58 percent or more by implementing simple lifestyle changes. Our program sets realistic goals of losing 5 to 7 percent of their starting weight during a twelve-month program including making healthier dietary choices, developing support systems and increasing physical activity. Classes are facilitated by trained lifestyle coaches who use facilitation to present material, instead of lectures.

Classes are typically limited to a small group, which facilitates developing support systems, empathy and acceptance. Effective management of diabetes impacts overall and long-term health. Below are some best practices in diabetes management that we know our providers are using.

  1. Annual HgbA1c testing and effective HgbA1c control (best practices recommend HgbA1c goals less than 7)
  2. Blood pressure control (best practices recommend blood pressure goals less than 129/79)
  3. Annual kidney function screening (members meet if prescribed an ACE/ARB medication, have a urine microalbumin test or see a nephrologist)
  4. Diabetic eye exam (best practices recommend an annual dilated eye exam to evaluate if diabetes is affecting vision and/or eye health)

Since a patient’s personal doctor directs his or her overall care, it’s important patients know the following when getting a diabetic eye exam.

  • That they have a diagnosis of diabetes
  • That the eye exam is dilated to evaluate for diabetic retinopathy
  • That the results of their eye exam be communicated to their personal doctor
Network Health has a Diabetic Retinopathy Report form which includes all of the necessary components of a dilated eye exam, which may be completed by the eyecare provider and returned to the patient’s personal doctor. For more information, contact QI@networkhealth.com.


Diagnosing Diabetic Retinopathy

Diabetes can damage a person’s eyes, and the only way to diagnose diabetic retinopathy is to have a dilated eye exam.

A dilated eye exam is recommended every other year when the person with diabetes is confirmed to be free of retinopathy on exam, and yearly otherwise.

To be certain credit is given, it is important to include CPT II 3072F on the eye exam claim when appropriate. For reference, below are all appropriate codes for eye exams, including codes that indicate the exam was done by a qualifying provider (optometrist/ophthalmologist).

Eye Exam (retinal or dilated) CPT II code 3072F reflects a dilated retinal exam negative for retinopathy. CPT

CPT CPT II HCPCS
67028, 67030, 67031, 67036, 67039-67043, 67101, 67105, 67107, 67108, 67110, 67112, 67113, 67121, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227, 67228, 92002, 92004, 92012, 92014, 92018, 92019, 92134, 92225-92228, 92230, 92235, 92240, 92250, 92260, 99203-99205, 99213-99215, 99242-99245 2022F, 2024F, 2026F, 3072F S0620, S0621, S3000

 

While it’s appropriate to continue to bill with CPT, CPT II and HCPCS codes for the services you render, please ensure you include the code that reflects a dilated retinal exam negative for retinopathy as appropriate to the exam, which is CPT II Code 3072F.

This helps to summarize the care provided most concisely and efficiently to be sure the patient’s care is documented accurately and completely.

If you have any questions, please contact Network Health’s Quality Health Integration team at qi@networkhealth.com.  

New $25 Insulin Program for Commercial Members

Beginning January 1, 2020, Network Health is introducing the Patient Assurance Program, which provides less expensive insulin options for our commercial members—including those who get insurance through their employer and those who purchase on their own.* The Milwaukee Courier recently ran this article about the new program: Network Health Will Offer Affordable Access to Insulin.

The Patient Assurance Program lists insulin as a preventive drug, which brings preferred brand (tier 3) insulin copayments down to $25 for a 30-day supply or $75 for a 3-month supply. This allows all commercial members—even those on HSA-qualified plans—to access this $25 insulin benefit before they meet their deductible.

To determine which drugs fit into this program, you can view and search our drug lists on the Look Up Medications page of our website.

*Not available for Medicare plans and transitional, grandmothered or grandfathered commercial plans.


2020 Annual Pharmacy Notification

Important pharmacy information, references and current contact lists are available at networkhealth.com/provider-resources/pharmacy-information.

Formulary Overview
You will find our online formularies via the Look Up Medications tool. If you would like a printed copy of a formulary, you may print the PDF documents directly from the website, or, you can contact our customer service department to have a copy mailed to you.

Network Health manages commercial, individual and family and Medicare formularies. All are very similar with slight differences in tier structures, drug tier placements, utilization management rules and other requirements or restrictions. Some of our utilization management strategies include prior authorizations, step therapy protocols, quantity level limits and specialty drug restrictions.

For commercial, individual and family and Medicare, these rules are created and reviewed independently through our pharmacy and therapeutics committee and are administered through our pharmacy benefits manager, Express Scripts, Inc. (ESI).

Effective January 1, 2020, ESI will administer prescription benefits for our commercial, individual and family and Medicare members, including the review of our utilization management rules and maintaining the pharmacy network. ESI is the designated contact for all clinical medication reviews, exceptions and authorizations, regardless of the drug or pharmacy. In addition, ESI offers mail order services for all commercial, exchange, Medicare and most self-insured plan members. Mail order for Network Health self-insured participants is handled through the Ascension WI Retail Pharmacy in Wausau.

Network Health Holidays

Network Health offices will be closed on the following dates.

  • Thursday, November 28
  • Friday, November 29
  • Tuesday, December 24
  • Wednesday, December 25

If you are not a current subscriber to The Consult and you would like to be added to the mailing list, please email us today. Current and archived issues of The Pulse, The Script and The Consult are available at networkhealth.com/provider-resources/news-and-announcements.

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