Winter 2021: Volume 4, Issue 1

We know that easy access to provider resources and information makes doing business with us easier. That’s why we have updated and posted our 2021 Provider Manual.

Please review the provider manual for our policies and procedures, prior authorization and claim information, and other useful reference materials.

The previous post office box where we received claim submissions closed at the end of November. We have acquired a new post office box at a new location, and we have set up auto-forwarding for one year to ensure that we receive any mail sent to the retired P.O. box. This will prevent interruptions in processing claim requests.

Please update your records with the new address for all paper claims, corrected claims, and/or provider appeals:

Commonwealth Care Alliance
P.O. Box 548
Greenland, NH 03840-0548

If you have any questions, please contact CCA Customer Service at 800-306-0732.

CCA is excited to announce that we began to serve eligible One Care members in Berkshire County starting on January 1, 2021. This expansion is inclusive of all cities and towns in Berkshire County. By contracting with Berkshire Medical Center, CCA is adding more than 800 providers to our network.

This expansion marks an important milestone for CCA, which is now the first One Care plan to operate in western Massachusetts, and the first One Care plan to serve eligible beneficiaries in all regions of mainland Massachusetts.

Moreover, CCA’s new service area expansion now includes all cities and towns in other approved counties for both CCA One Care and CCA Senior Care Options (SCO). The following links provide service area details:

• CCA One Care Eligibility
• CCA SCO Eligibility

In support of CMS requirements, please note that CCA requires a prescription for all DME and medical supply orders. The prescription also becomes important supporting documentation if a vendor is asked to submit records for a claims audit. For more information, please contact the DME & Supply Procurement Unit at 866-610-2273 Ext 8330.

During the rapidly evolving situation around COVID-19, Commonwealth Care Alliance (CCA) continues to follow the recommendations from the Centers for Disease Control and Prevention (CDC) and the Massachusetts Department of Public Health (DPH) to keep our members and employees safe. We encourage providers to consult the CDC,¹ DPH,¹ and Mass.gov coronavirus¹ websites for the most up-to-date information. Please continue checking the CCA website, as we will continue to provide updates as they become available.

For timely and accurate processing of prior authorization (PA) requests, it is important that the Standardized Prior Authorization form is filled out completely with the correct information. Please note: All fields on this form marked with an asterisk (*) are required fields. Below are some commonly incomplete fields that delay processing of PA requests.

Provider Fields:
Include both name and NPI number for:

• Requesting provider
• Servicing provider
• Servicing facility

The servicing facility should represent the location where the requested services will take place.

Diagnosis and Codes:
A prior authorization request cannot be processed without:

• CPT/HCPCS codes
• the number of units for each code
• the dates of service
• ICD-10 diagnosis codes

Any omission of this information will result in an outreach to the requesting provider for clarification and will delay the processing of the authorization.

PA Requests and Clinical Documentation:
Please include clinical documentation when submitting a PA form for CCA to process requests as quickly as possible, and to prevent an outreach phone call.

PA Requests for Multiple Members:
Please submit PA requests for each member separately for CCA to process requests as quickly as possible and to comply with HIPAA regulations. This will prevent an outreach phone call asking for resubmission of your request.

We have found that some providers are using old CCA Prior Authorization forms. These old forms lack the necessary fields to complete the authorization process in a timely and accurate manner. Please use only the current forms that can be found on the CCA website on the “For Providers” page. We have provided the link below for your convenience.

Link to current PA form

In the first 200 days of the COVID-19 pandemic in Massachusetts, CCA utilized predictive analytics to identify and prioritize members most at-risk for serious complications from the virus. We have also engaged members through telehealth and in-person visits and started a Member Support Program to help members get household items such as toilet paper and cleaning supplies. Learn more about our response to COVID-19 here.¹

Controlling Diabetes

Background
Among the HEDIS 2021 measure sets are those which strive to assess the quality of care provided to members for their chronic illnesses. This includes, but is not limited to, the Comprehensive Diabetes Care measure—developed to ensure the proper management of multiple disease factors key to ensuring control of diabetes and the avoidance of downstream sequelae.

Comprehensive Diabetes Care criteria
The Comprehensive Diabetes Care criteria ensure that the appropriate members are assessed for the appropriate care. This includes factors of controlling blood pressure, managing HbA1c, checking for kidney status, and examinations for diabetic retinopathy. Below are details:

Description
The percentage of members 18–75 years of age with diabetes (type 1 and type 2) who had each of the following:

• Hemoglobin A1c (HbA1c) testing
• HbA1c poor control
• Eye exam (retinal) performed
• Medical attention for nephropathy
• BP control (<140/90 mm Hg)

Criteria for Medical Record Details

HbA1c
At a minimum, documentation in the medical record must include a note indicating the date when the HbA1c test was AND the result or finding. Count notation of the following in the medical record:

Eye Exam
Screening or monitoring for diabetic retinal disease as identified by administrative data or medical record review. This includes diabetics who had one of the following:

• A retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) in the measurement year
• A negative retinal or dilated exam (negative for retinopathy) by an eye care professional in the year prior to the measurement year
• Bilateral eye enucleation any time during the member’s history through December 31 of the measurement year

At a minimum, documentation in the medical record must include one of the following:

• A note or letter prepared by an ophthalmologist, optometrist, PCP, or other health care professional indicating that an ophthalmoscopic exam was completed by an eye care professional, the date when the procedure was performed, and the results
• A chart or photograph indicating the date when the fundus photography was performed and evidence that an eye care professional reviewed the results. Alternatively, results may be read by a qualified reading center that operates under the direction of a medical director who is a retinal specialist.
• Evidence that the member had bilateral eye enucleation or acquired absence of both eyes
• Documentation of a negative retinal or dilated exam by an eye care professional in the year prior to the measurement year, where results indicate retinopathy was not present (e.g., documentation of normal findings)
  • Documentation does not have to state specifically “no diabetic retinopathy” to be considered negative for retinopathy; however, it must be clear that the patient had a dilated or retinal eye exam by an eye care professional and that retinopathy was not present. Notation limited to a statement that indicates “diabetes without complications” does not meet criteria

Medical Attention for Nephropathy
Any of the following during the measurement year meet criteria for a nephropathy screening or monitoring test or evidence of nephropathy.

• A urine test for albumin or protein. At a minimum, documentation must include a note indicating the date when a urine test was performed, AND the result or finding. Any of the following meet the criteria:
  • 24-hour urine for albumin or protein
  • Spot urine (e.g., urine dipstick or test strip) for albumin or protein
  • Urine for albumin/creatinine ratio
  • Random urine for protein/creatinine ratio
  • Timed urine for albumin or protein
  • 24-hour urine for total protein
  • Random urine for protein/creatinine ratio
• Documentation of a visit to a nephrologist
• Documentation of a renal transplant
• Documentation of medical attention for any of the following (no restriction on provider type):

• Evidence of ACE inhibitor/ARB therapy. Documentation in the medical record must include evidence that the member received ACE inhibitor/ARB therapy during the measurement year. Any of the following meet criteria:
  • Documentation that a prescription for an ACE inhibitor/ARB was written during the measurement year
  • Documentation that a prescription for an ACE inhibitor/ARB was filled during the measurement year
  • Documentation that the member took an ACE inhibitor/ARB during the measurement year

Blood Pressure Control <140/<90
Identify the most recent BP reading noted during the measurement year. Identify the lowest systolic and lowest diastolic BP reading from the most recent BP notation in the medical record. If multiple readings were recorded for a single date, use the lowest systolic and lowest diastolic BP on that date as the representative BP. The systolic and diastolic results do not need to be from the same reading.

Do not include BP readings that meet the following criteria:

• Taken during an acute inpatient stay or an ED visit
• Taken on the same day as a diagnostic test or diagnostic or therapeutic procedure that requires a change in diet or change in medication on or one day before the day of the test or procedure, with the exception of fasting blood tests
• Reported by or taken by the member

BP readings from remote monitoring devices that are digitally stored and transmitted to the provider may be included. There must be documentation in the medical record that clearly states the reading was taken by an electronic device, and that the results were digitally stored and transmitted to the provider for interpretation.

Providers are required to confirm a patient’s CCA eligibility prior to rendering services. It’s important to remember that a prior authorization is contingent upon a member’s active eligibility on the dates of service.

Here’s how to quickly confirm a patient’s CCA eligibility:

• Log onto the EZ NET Online Claims Web Portal¹
• Use the MassHealth Provider Online Service Center¹
• Using the NEHEN Provider Portal¹
• CCA Provider Services at 866-420-9332

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.

Please call 866-420-9332, Monday through Friday, from 8 am to 6 pm, or visit our Provider Resource page for more information on the Provider Services line and self-service options.

You can find key resources to support CCA members in our updated Provider Manual. This includes an up-to-date contact list available online. View the Provider Manual Contact List.