Welcome to the Fall Edition of CCA Provider News!
Our Fall Provider e-Newsletter contains the latest updates about prior authorization, Medicare’s Annual Enrollment Period and step therapy guidance, and our flu shot efforts. You’ll also find information about the Provider Services line and automated preventive care calls to members.
- CCA updated our care model so there is team-based responsibility for each member.
- The updated model will allow for better collaboration with you.
- CCA has improved the provider call experience to expedite how you connect with CCA, from clinical issues to claims.
On September 14, Commonwealth Care Alliance (CCA) made enhancements to the CCA care model to empower our care teams and efficiently serve our members.
Here are details around what these improvements mean for you:
The team structure has been updated to streamline and clarify roles.
- Every member has been assigned a care partner who will remain with the member regardless of changes in conditions or needs. This dedicated care partner will focus exclusively on care coordination.
- The care partner will be responsible for leveraging their Care Partnership team of mobile nurse practitioners, registered nurses, behavioral health specialists, and health outreach workers to follow members longitudinally for chronic diseases and short-term urgent needs. The care partner will lead daily “huddles” to keep the team updated on members’ needs.
- The care partner will ensure that a post-hospital visit is scheduled to decrease 30-day readmissions.
- The Care Partnership team will collaborate with primary care providers to deliver enhanced primary care to the most acute and vulnerable members. The care partner will provide you with regular updates
- CCA has improved the provider phone experience with a new dedicated provider line. This line has new prompts to connect you more directly to the resources you need, from clinical to claims. These new prompts provide an efficient pathway to connect with your patient’s care partner for clinical concerns. The Provider Services number is (866) 420-9332. Please select option 4 if you have clinical concerns and would like to reach your patient’s care partner.
Thank you for being in our provider network and for your interest in these updates.
CCA engages our members around the preventive care services they need to stay healthy and independent. One way we do this is through automated voice calls that inform patients when they are due for selected services. Since introducing these calls, we’ve seen an increase in the use of preventive services among our members. In 2020, our automated calls will run from July through October and may address:
- Preventive Dental Care
- Breast Cancer Screening
- Diabetic Eye Exam and Kidney Testing
- Annual Flu Vaccine
Phone Call Details
All automated outreach calls to CCA members will come from a local Massachusetts phone number. After we confirm member identity, members will hear a description of the service and are given the opportunity to transfer to Member Services. Our Member Services team will help them schedule the appointment and coordinate transportation.
If you have a question or concern about these automated voice calls, please contact CCA Member Services Department at 866-610-2273 (TTY 711).
CCA is highly committed to our members’ wellness and preventive health initiatives. This year more than ever, we are encouraging members to get the flu shot and we need your help!
Why Patients Need to Get the Flu Shot
The Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) are recommending more people get the flu vaccine this year. There is evidence to suggest that when people’s immune system is weak from an illness like the flu, they may be more susceptible to illnesses like COVID-19. Protection from the flu will reduce hospitalizations and the burden on hospitals ahead of anticipated COVID-19 spread.
When to Get the Flu Shot?
The CDC recommends people get a flu vaccine by the end of October because it takes a few weeks for the vaccine to become fully protective. However, getting the flu shot later in the season is better than not getting it at all.
Who Should Get the Flu Shot?
The CDC recommends annual influenza vaccinations for everyone age 6 months or older. Vaccinations are especially important for people with chronic medical conditions.
Remind and Reassure Patients the Flu Vaccine Cannot Give Them the Flu
The flu vaccine cannot give people the flu. It prevents serious complications from the flu. However, some people do experience mild symptoms they think are the flu. Those who get the flu after being immunized have less severe symptoms and have a reduced risk of being hospitalized with complications.
What Can You Do as a Provider to Encourage Patients to Get the Flu Shot?
- Encourage all of your patients to get the flu vaccine. If your office is not administering the vaccine, encourage patients to go to their local pharmacies or community flu clinics.
- Please call and let us know if you provide one of our members the vaccine so we can add it to their medical record. You can call the Provider Services line at 866-420-9332, Monday through Friday, from 8:00 a.m. to 6:00 p.m.
- Encourage your patients’ family members and friends to get the flu shot as well. It takes a village to keep our patients healthy.
On August 7, 2018, the Centers for Medicare & Medicaid Services (CMS) issued guidance acknowledging the use of step therapy as a recognized utilization management tool for Part B medical drugs. Implementing step therapy practices for Part B drugs will help achieve the goal of lowering drug prices while maintaining access to covered services and drugs for members.
Step therapy is a type of prior authorization for drugs that begins medication for a medical condition with the most preferred drug therapy and progresses to other therapies only if necessary, promoting optimal clinical decisions.
Effective December 1, 2020, Commonwealth Care Alliance will be implementing step therapy for a select number of Part B medical drugs. The drugs selected for step therapy have biosimilars available.
A biosimilar is a biological product approved based on data demonstrating that it is highly similar to an FDA-approved biological product, known as the reference product, and that there are no clinically significant differences between the biosimilar product and the reference product. Biosimilars are at least likely to produce equivalent therapeutic results and are lower cost than brand name alternatives.
For more information, please see Commonwealth Care Alliance’s Medicare Part B Step Therapy Program Policy.
Medicare’s Annual Election Period (AEP) is here! You can expect that your older patients will start asking you for advice as they are seeing more advertising about enrolling in a Medicare plan.
You need to know that the AEP applies to dual-eligible seniors applying for a Senior Care Options (SCO) plan as well. However, it does not apply to seniors with Mass Health Standard but not Medicare.
AEP runs from October 15 through December 7. During this period, your patients who are 65 and over and have both MassHealth Standard and Medicare can join a SCO plan for coverage effective on January 1, 2021. If they do not enroll during this AEP period, they may have to wait a bit longer to start receiving the coordinated care and extra benefits with being enrolled in our Senior Care Options plan.
There are some exceptions that may allow a dual-eligible senior patient to enroll at any time during Q4 with a coverage date of the first of the next month, e.g., November 1, December 1, and January 1. The most common exceptions are:
- Turning 65 during the quarter, i.e., “aging into Medicare”
- Moving into the health plan enrollment area
- Becoming eligible for MassHealth Standard
In January, your dual eligible seniors can once again enroll for the first of the next month.
No need to memorize that – our agents will work with any patients you refer to determine whether their specific circumstances qualify them for any exceptions.
If you have any questions or would like to refer any of your patients please feel free to call us at (857) 488-9512, email us at [email protected]. You can also refer your patients to our online referral forms, which can be found here.
The Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by more than 90 percent of America’s health plans to measure performance on important dimensions of care and service. Altogether, HEDIS consists of more than 70 measures across five domains of care. Because so many plans collect HEDIS data, and because the measures are so specifically defined, HEDIS makes it possible to equitably compare the performance of health plans across the nation.
Commonwealth Care Alliance (CCA) participates in the annual HEDIS assessment as required by MassHealth and the Centers for Medicare & Medicaid Services (CMS). Resultant rates serve to validate corporate quality improvement initiatives and inform the CMS Star Ratings and the State Withhold and Custom measures. HEDIS is operationalized by CCA’s Quality department, with assistance from a team of per diem medical record review RNs. HEDIS is a multi-focal engagement, requiring analysis of various data files to establish claims rates and various medical record reviews to provide clinical assessment.
CCA began participating in HEDIS in 2008, with immediate participation of the Senior Care Options (SCO) plan. One Care began implementing HEDIS in 2015. Below are key 2020 (MY2019) HEDIS Survey Results for each plan.
Table 1: Key 2020 (MY2019) HEDIS Survey Results – SCO
|Adult BMI Assessment||100%|
|Colorectal Cancer Screening||80%|
|Persistence of Beta-Blocker Treatment After a Heart Attack||100%|
|Hemoglobin A1c testing – Diabetes||97%|
|Medical Attention for Nephropathy – Diabetes||95%|
|Eye Exam – Diabetes||84%|
Table 2: Key 2020 (MY2019) HEDIS Survey Results – ICO
|Adult BMI Assessment||95%|
|Colorectal Cancer Screening||71%|
|Persistence of Beta-Blocker Treatment After a Heart Attack||88%|
|Hemoglobin A1c testing – Diabetes||93%|
|Medical Attention for Nephropathy – Diabetes||93%|
|Eye Exam – Diabetes||72%|
The 2020 HEDIS Season began immediately prior to the outbreak of the COVID-19 pandemic and was, as such, directly affected by it. Shortly after the virus outbreak became global, the National Committee for Quality Assurances (NCQA), CMS and State regulatory agencies elected to restrict Plans’ access to provider offices, severely limiting the collection of medical records. Due to CCA’s access to many provider records through remote electronic means, CCA was able to review many medical records; however, a significant amount remained unavailable. Lower rates for hybrid measures was the direct result. To level the playing field CMS – similar to NCQA and States for Commercial Plans – allowed Medicare Plans to rotate in 2019 hybrid rates for their 2020 rates.
To support our Provider Network and ensure you have the best experience possible, we want to remind you that the new dedicated Provider Line is live.
CCA went live with the new dedicated Provider Line on July 6, 2020.
To better service our members and provider partners, CCA would like to remind you of our prior authorization process. For more information about prior authorization, please refer to the Provider Manual located on the CCA website.
When should I ask for prior authorization?
CCA requires a Prior Authorization for a select group of items and services. You can find our covered services and PA Requirements here.
How can I get prior authorization?
Use CCA’s Standard Prior Authorization Request Form, which can be located here. Complete the form including service/ procedure codes, frequency and units, and start and end date. Attach all clinical documentation to support the request and fax to 855-341-0720.
Do emergency services require prior authorization?
No, CCA does not require prior authorization for emergency services.
How can I speed up the prior authorization process?
When submitting your prior authorization request, include all documentation to support the medical necessity. CCA utilizes Medicare and Medicaid coverage guidelines, as well as best practice and evidence based criteria and guidelines to make decisions on prior authorizations. As a provider, you can assist by submitting concise, complete, and quality information with your prior authorization request. This will ensure that the Utilization Management staff can conduct a full and meaningful review. By providing this information, you can eliminate the need for additional outreach to your office for missing or incomplete information. This also helps reduce prior authorization denials. Our goal is to ensure that our members receive the medically necessary services that maintain or restores their health and wellbeing.
When should I expedite a request?
An expedited prior authorization request can be made by a member or their physician when they believe that applying the standard timeframe could seriously jeopardize the life or health of the member, or their ability to regain maximum function. Making expedited requests should be the exception and not general office practice. Inappropriately requesting expedited authorizations can lead to a delay in the overall turnaround time of all authorization requests. Please be mindful of appropriately applying the definition, and the utilization of expedited requests.
Expedited should not be used for:
- Services where member’s life or health are not jeopardized by waiting the standard timeframe.
- Services that have already been provided.
- Services with a start date 14 or more days into the future.
- Untimely submission of the request.
- Emergency services
When will I be notified about a prior authorization decision?
CCA automatically sends a notification to the member and provider once a decision is made. Providers receive a fax letter from CCA. To ensure that the fax is received at the correct location, please include in the prior authorization request the fax number you would like the notification to be sent to.
If you do not receive a notification, please call CCA’s Provider Services line at 866-420-9332, Monday through Friday, 8:00 a.m. to 6:00 p.m. to request that it be resent.
Keeping your information up-to-date in our Provider Directory helps your practice by making it easier for our members to find your practice locations. Updating your information in our health plan provider directories also helps our members:
- Get easy access to your services.
- Receive important information about your practice
Your Assistance is Greatly Appreciated!
If you wish to provide your updated information to CCA, please email us at [email protected].
Learn more about the CMS Provider Directory regulations on our website here.