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TRANSCRIPT
Healthy Blue 2019 provider
educational workshop
Provider education territory map
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What’s new?
• Revised website
• BabyNet
• Adult vision
• Behavioral Health
• IngenioRx
• CLIA* certificate ID requirement
• New ID cards
• Provider enrollment process
* Clinical Laboratory Improvement Amendments
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Healthy Blue contact information
Website: www.HealthyBlueSC.com > Providers
Customer Care Center:
• Phone: 866-757-8286 TTY: 866-773-9634
• Fax: 912-233-4010 or 912-235-3246 Hours: Monday through Friday from 8 a.m. to 6 p.m.
24/7 Pharmacy Member Services:
• Phone: 833-207-3118 TTY: 711
Utilization Management (UM) department:
• Phone: 866-902-1689
• Fax: 800-823-5520
• Hours: Monday through Friday from 8 a.m. to 5 p.m.
24/7 NurseLine:
• Phone: 866-577-9710
• TTY: 800-368-4424
Case Management (CM) department:
• Phone: 866-757-8286
• Hours: Monday through Friday from 8 a.m. to 5 p.m.
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Healthy Blue contact information
(cont.)Disease Management (DM) department:
• Phone: 888-830-4300
• TTY: 800-855-2880
• Hours: Monday through Friday from 8 a.m. to 5 p.m. EST
Vision Service Plan (VSP):
VSP is an independent company that offers a vision network on behalf of BlueChoice HealthPlan.
• Phone: 800-615-1883
• Hours: Monday through Friday from 8 a.m. to 5 p.m.
Saturday from 10 a.m. to 3 p.m.
Sunday from 10 a.m. to 4 p.m.
IngenioRx
IngenioRx provides pharmacy benefits on behalf of BlueChoice HealthPlan.
Prior authorizations 844-410-6890
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Primary care access and availability
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Visit type: Availability standard:
Routine visit Within four weeks
Urgent, nonemergent visit Within 48 hours
Emergent visitImmediately scheduled upon presentation at a
service delivery site
• Wait times must not exceed 45 minutes for a routine, scheduled
appointment.
• Walk-in patients with nonurgent needs should be seen or scheduled for an
appointment.
• 24-hour coverage by direct access or through arrangements with a triage
system should be provided.
Specialist care access and
availability
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Visit type: Availability standard:
Routine visitWithin four weeks;
maximum of 12 weeks for unique specialists
Urgent medical condition care
appointment
Within 48 hours of referral or notification from
PCP
Emergent visit Immediately upon referral
Covered benefits
Need to know if a code is covered or the reimbursement for a code?
https://www.scdhhs.gov/resource/fee-schedules
Fee schedules are listed by provider specialty type. If the code appears on the SCDHHS fee schedule, it is covered.
The reimbursement for each code is also listed.
• Medicaid Managed Care Organization (MCO) plans are required to offer at a minimum the same benefits as Healthy Connections Fee for Service (FFS).
• Plans can choose to offer additional benefits.
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Covered benefits (cont.)
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Need to know the policy for a certain service?https://www.scdhhs.gov/provider-manual-list
BabyNet
BabyNet is South Carolina’s early intervention system for infants and toddlers under three years of age with developmental delays, or who have conditions associated with developmental delays. • Ages 0–3 years• All current Medicaid services are included in BabyNet• All services rendered for BabyNet from Oct. 1, 2019 to Dec. 31, 2019 do
not require prior authorization (PA)
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Durable medical equipment
Healthy Blue covers durable medical equipment (DME) when prescribed to
preserve bodily functions or prevent disability:
• $3.40 copay per item.
• Appropriate modifiers must be used to identify rental versus purchase (new or used).
• We require medical documentation from the prescribing doctor for DME rentals. Most DME is dispensed on a rental basis only.
• Rented items remain the property of the DME provider until the purchase price is reached.
• We may cover DME on a rent-to-purchase basis over a period of 10 months, unless specified otherwise at the time of UM review.
Authorizations:
• All custom-made DME requires prior authorization.
• If unsure if authorization is required, contact utilization management.866-902-1689.
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Home health services
Healthy Blue covers intermittent skilled nursing, home health aide
services, physical, occupational and speech therapy services and
physician-ordered supplies.
Home health services have a copay of $3.30.
Members have a 50-visit limit on home health services with these
codes: 36415, S9128, S9129, S9131, T1021, T1028, T1030, T1031.
Authorizations:
• Healthy Blue requires prior authorization for all home health care.
(Services are authorized for a 30-day duration.)
• Contact UM to request authorization for Home Health services:
1-866-902-1689
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Physical, occupational and speech
therapy• Healthy Blue covers outpatient services to include physical, occupational and speech
therapy.
– Members pay a $3.30 copay.
– Members who are 21 years of age and older have a limit of 75 combined visits or
300 units per benefit year.
– Members who are under 21 years of age receiving therapy are limited to 105
combined visits or 420 units per benefit year.
• Authorizations:
– Codes that always require PA: 97022, 97140, 97150, 97166, 97167.
– All other codes or any services beyond the benefit maximum require medical
review and prior authorization.
– Contact utilization management to request authorization for these services 1-
866-902-1689.
To determine how many visits a member has used, please contact the Customer Care
Center.
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Physicals
• Adult routine physicals are covered once every two years.
• Sports physicals are covered under the following circumstances:
– Provided by an in-network primary care provider.
– Covered once per calendar year.
– Covered for members 6 to 18 years of age.
– Bill using CPT code 99212 and diagnosis Z02.5.
– This can be billed in addition to a well-child exam and the
well child incentive.
– Reimbursement is $30.
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Routine vision servicesRoutine vision services for Healthy Blue members under 21 years of age are covered through Vision Service Plan (VSP).
Copay: none for members under 19
Covered services
• One routine eye exam every 12 months
• One pair of eyeglasses (frames and lenses) and related fitting every 12 months.
When medically necessary, and approved ahead of time, other services are covered during the 365 -day period.
For PA and information, call VSP at 800-615-1883.
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Adult vision servicesHealthy Blue now covers routine vision services for members ages 21 and up through VSP.
Copay: $3.30
Covered services
• One routine eye exam every 12 months
• One pair of eyeglasses (frames and lenses) and related fitting every 24 months.
When medically necessary, and approved ahead of time, other services are covered during the 365 -day period.
For PA and information, call VSP at 800-615-1883.
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VSP-covered codes
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Medical vision services
Healthy Blue covers medical vision services rendered by
an ophthalmologist. Claims for these services are filed
directly to Healthy Blue.
Copay: $3.30 for members 19 years and older.
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AIM Specialty Health
AIM Specialty Health® is an independent company that provides utilization review services on behalf of BlueChoice HealthPlan. AIM handles advanced imaging and cardiology authorizations for the following services:• Computed tomography scans (including cardiac) • Magnetic resonance imaging (including cardiac) • Positron emission tomography scans (including cardiac) • Nuclear cardiology • Stress echocardiography • Resting transthoracic echocardiography • Transesophageal echocardiography • Arterial ultrasound • Cardiac catheterization • Percutaneous coronary intervention (PCI)
We understand that the need for arterial duplex imaging or PCI procedures may not be identified until patients have undergone a physiologic study or cardiac catheterization. For these cases, please contact AIM to request clinical appropriateness review no later than 10 business days after you perform these procedures (and before you submit a claim). For all other cases, please contact AIM to obtain authorization before you perform the procedure.
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AIM Specialty Health (cont.)
AIM also handles authorizations for the following radiation oncology services:
• Brachytherapy
• Intensity modulated radiation therapy
• Proton beam radiation therapy
• Stereotactic radiosurgery/stereotactic body radiotherapy
• 3D conformal therapy (EBRT) for bone metastases and breast cancer
• Hypofractionation for bone metastases and breast cancer when requesting EBRT and
intensity modulated radiation therapy (IMRT)
• Special procedures and consultations associated with a treatment plan (CPT codes
77370 and 77470)
• Image guided radiation therapy
Radiation oncology performed as part of an inpatient admission is not part of the AIM
program. Radiation oncology providers are strongly encouraged to verify that
authorization has been obtained before initiating, scheduling and performing services.
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AIM Specialty Health (cont.)
If AIM authorizes the service, AIM provides an order number to the ordering provider. AIM
sends this approved authorization to Healthy Blue who assigns an actual authorization
number.
Please file the authorization number on the claim and not the AIM order number. Filing
the AIM order number on the claim may result in a denial of the claim.
The ProviderPortalSM is the fastest, easiest way to contact AIM. As an online application,
ProviderPortal offers a convenient way to enter your authorization requests or check on
the status of your previous authorizations. Go to https://www.providerportal.com * to
begin. Registration is required.
For questions regarding your online authorization, please contact the AIM ProviderPortal
Support team at 800-252-2021.
* This link leads to a third-party site. That organization is solely responsible for the contents and privacy policies on its site.
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Behavioral health covered services
• Inpatient services provided in a general acute care hospital
• Professional psychiatric services
• Outpatient services provided by licensed independent practitioners (LIPs), group practices, Federally Qualified Health Centers (FQHCs) and rural health clinics (RHCs) including psychiatrists and advanced nurse practitioners
• Substance abuse services provided by any of the Department of Alcohol and Other Drug Abuse Services (DAODAS) commissions
• Autism services
• Psychiatric residential treatment facility (PRTF) services
• Rehabilitative behavioral health services (RBHS)
• Opioid Treatment Program (OTP) – carved in July 1, 2019
• Institute for Mental Disease (IMD) – carved in July 1, 2019
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Rehabilitative Behavioral Health
ServicesRehabilitative Behavioral Health Services (RBHS) are services provided by licensed independent practitioners (LIPs), or providers in the South Carolina Department of Alcohol and Other Drug Abuse Services (DAODAS) network, the South Carolina Department of Mental Health (DMH) network, or the South Carolina Department of Education (DOE) network.
Documentation required when submitting for prior authorization:
• Prior authorization form (specific to your agency or the Rehabilitative Behavioral Health Services Treatment Review and Authorization Request Form found on the Healthy Blue website) in addition to Diagnostic Assessment, Treatment Plan of Care, which includes services delivered.
• Any additional clinical information the provider feels supports the request including treatment updates if the Diagnostic Assessment is more than three months old.
All out of network providers require authorization for all services regardless of provider type.
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Institute for Mental Disease services
An Institute for Mental Disease (IMD) is often referred as a
free-standing psychiatric facility.
• IMDs are covered for members ages birth to 21 years of
age.
• All IMD services require prior authorization.
• If you have a member receiving IMD services, please
contact our Behavioral Health Utilization Review
Department at 866-902-1689 select option 3.
• Certification of Need can be faxed to 877-664-1499.
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Opioid Treatment Program
The Opioid Treatment Program (OTP) consists of outpatient substance use
treatment services for members who have an opioid use disorder and are
receiving medication-assisted treatment and psychoeducational services.
• There are no age restrictions for participation.
• OTP services do not require authorization.
Procedure codes filed for OTP:
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Procedure code Service description Billing frequency
H0047 Medication assisted treatment (MAT)
assessment
At time of admission and for
annual determination of
medical necessity
H0016 Buprenorphine maintenance
treatment
Billed weekly
H0020 Methadone maintenance treatment Billed weekly
Behavioral Health resources
The following provider resources are available from Healthy Blue:
• Clinical Practice Guidelines
• BH Outpatient Treatment Request Form
• BH Data Sharing Form
• Psychological Testing Request Form
• Provider Guide
• ASD Testing Authorization Form
• ASD Services Request Form
• PRTF PA Form
• RBHS BH Treatment Review and Authorization Request Form
• RBHS Progress Note Form
• Dispute forms
To view provider resources, visit www.HealthyBlueSC.com and select Providers.
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Behavioral health credentialing
Companion Benefits Alternatives (CBA) coordinates credentialing for mental health practitioners. CBA is a separate company that administers mental health and substance abuse benefits on behalf of BlueChoice HealthPlan.
These items are needed when submitting a provider for credentialing through CBA:
• Completed application (the CBA application rather than the SC Uniform application)
• Completed W9 Form or appropriate IRS documentation (letter 147C, CP 575 E or tax coupon 8109-C)
• Healthy Blue MCO Agreement (MDs/DOs = physician agreement, all others = ancillary agreement)
• Disclosure of Ownership Statement
• Copy of state license
• Copy of Drug Enforcement Administration (DEA) license (if applicable)
• Medicaid number (required for network participation)
• Proof of current malpractice coverage*
* Coverage minimums:
• For medical doctors = Joint Underwriters Association/Patient Compensation Fund or $1,000,000/$3,000,000
• All others = $1,000,000/$1,000,000
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Copays
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Copay exceptions
Members who are exempt from copay requirements:
• Children under 19 years of age
• Pregnant women
• Institutionalized individuals
• Individuals receiving emergency services in the emergency room
• Individuals receiving Medicaid hospice services
• Members of a federally recognized American Indian tribe (exempt when Catawba Service Unit in Rock Hill renders services and when referred to a specialist by Catawba)
Services that are not subject to copays:
• Medical equipment and supplies provided by the South Carolina Department of Health and Environmental Control (SCDHEC)
• Family planning services
• End-stage renal disease services
• Infusion center services
• Services provided in urgent/minor care clinics
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Pharmacy benefit manager change to
IngenioRxEffective October 1, 2019, IngenioRx became the pharmacy benefit manager (PBM) for prescription drugs and specialty pharmacy for Healthy Blue members. IngenioRx is an independent company providing pharmacy benefit management services on behalf of BlueChoice HealthPlan.
Members will be assisted in transferring their specialty prescriptions to our new in-network specialty pharmacy – IngenioRx Specialty Pharmacy. Accredo Specialty Pharmacy is no longer in-network.
Certain specialty prescriptions including compounds or controlled substances may require a new prescription to be sent to IngenioRx Specialty Pharmacy.
• IngenioRx Specialty Pharmacy phone: 833-255-0646
The prior authorization process for retail medications and specialty drugs (pharmacy benefit) will not change. You may continue to utilize the same phone and fax numbers.
• Phone: 844-410-6890
• Fax: 844-512-9005
The prior authorization process for medical injectables (medical benefit) will not change. You may continue to utilize the same phone and fax numbers for health plan Utilization Management review.
• Phone: 866-902-1689
• Fax: 800-823-5520
For questions about this change, please contact:
• Pharmacy Member Services (24/7): 833-207-3118
• Customer Care Center: 866-781-5094
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Prescription authorizations
• All medications will be limited to a one-month (maximum 31-day)
supply at all retail pharmacies.
• Members should refer to their Evidence of Coverage (EOC) for
benefit details, exclusions and limitations.
IngenioRx prior authorizations:
• 844-410-6890
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Did you know?
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You can now search our
website for preferred
formulary drugs?
Most preferred drugs do not
require PA where as
nonpreferred drugs always
require an authorization.
Laboratory services
• Healthy Blue has a preferred agreement with LabCorp for labs and
do not require precertification. LabCorp is an independent company
that provides laboratory services on behalf of BlueChoice
HealthPlan.
• You can send anatomical pathology and cytology specimens to a
local contracted pathology group or to LabCorp without
precertification.
• Refer to the Provider Manual for a complete list of labs that can
performed in your office and billed to Healthy Blue.
• You can send Special Tertiary Admissions Test (STAT) labs to a
contracted hospital.
• All other labs should be directed to LabCorp.
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CLIA certificate ID number
requirementsTo be considered for reimbursement of clinical laboratory services, a valid Clinical Laboratory Improvement
Amendments (CLIA) certificate identification number must be reported on a 1500 Health Insurance Claim Form (CMS-
1500) or its electronic equivalent beginning March 1, 2020. The CLIA certificate identification number must be submitted
in one of the following ways:
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Claim format and elements CLIA number location options Referring provider name and NPI number location options
Servicing laboratory physical location
CMS-1500 (formerly HCFA-1500) Must be represented in field 23 Submit the referring provider name and NPI number in fields 17 and 17b, respectively.
Submit the servicing provider name, full physical address and NPI number in fields 32 and 32A, respectively, if the address is not equal to the billing provider address. The servicing provider address must match the address associated with the CLIA ID entered in field 23.
HIPAA 5010 837 Professional Must be represented in the 2300 loop, REF02 element, with qualifier of X4 in REF01
Submit the referring provider name and NPI number in the 2310A loop, NM1 segment.
Physical address of servicing provider must be represented in the 2310C loop if not equal to the billing provider address and must match the address associated with the CLIA ID submitted in the 2300 loop, REF02.
LogistiCare
LogistiCare is an independent company that provides transportation services on
behalf of BlueChoice HealthPlan.
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Availity
Availity gives providers the
ability to quickly:
• Check claim status.
• Check member eligibility.
• View remittances.
• File claims – at no cost.
• Submit disputes and
appeals.
Availity is an independent
company that provides a
secure web portal on behalf of
BlueChoice HealthPlan.
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Please contact our Utilization Management department should you need to verify if a
service requires authorization: 866-902-1689.
Claims submission
Claim filing limits (original claim) All providers are allowed 365 days to submit claims.
Electronic data interchange (EDI): Payer ID 00403
• EDI is the preferred and fastest way to submit your claims.
• For set-up and information, call 800-470-9630.
AvailityClaims can be filed on the Availity website at no charge to the provider.
Hard copyIf you need to file a hard copy claim or submit a corrected claim, please mail to:
Healthy Blue
ATTN: Medicaid Claims
P.O. Box 100124 Columbia, SC 29202-3124
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Corrected claims and requested
medical records
Claim filing limits (corrected claims)
All providers are allowed 90 days to submit a corrected claim.
Corrected claims can be filed several ways:
• Availity: To send a corrected claim, select Replacement of Prior Claim in the field
titled Billing Frequencies.
• Electronically:
• Use loop 2300 and segment REF02 to indicate the original claim number.
• Use loop 2300 and segment CLM05-3 to indicate the claim frequency code.
• 7 = replacement of a prior claim.
• Hard copy: If you need to submit a hardcopy corrected claim, please mail to:
Healthy Blue
ATTN: Medicaid Claims
PO Box 100124
Columbia, SC 29202-3124
Claims denied for requests for medical records
We must receive medical records within 60 days of the request.
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Corrected claims
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If submitting hardcopy, please
submit the Corrected Claim Form:
Overpayment recovery addresses
Overpayment recovery:
Healthy Blue
P.O. Box 73651
Cleveland, OH 44193-1177
Overpayment recovery for overnight
delivery:
Healthy Blue
4100 W 150th St.
Cleveland, OH 44135
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Claims workflow
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Provider receives a denial/questions a payment.
Call the Customer Care Center at 866-757-8286. Obtain name
and call reference number.
Access Availity for additional claims
processing information.
Contact your Provider Services representative
(provide the name and call reference number).
Issue resolved
Issue resolved
Most common denials
R00000 denials (not all inclusive) are:
• Procedure code not on fee schedule.
• Procedure code does not match with
diagnosis.
• VSP did not provide the vision
services.
• Billed with a modifier inappropriate
for procedure.
• Billed in excess of maximum allowed
by Medicaid.
• Claim amount was paid by other
insurance carrier.
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Misc. R0000038%
Other Health Insurance
28%
Member Not Eligible
26%
No Authorization8%
Verifying eligibility
Please check member eligibility during each visit!
After being newly assigned to a health plan, a member can change plans within his or her initial 90 days.
• Members may also lose eligibility due to status change.
Ways to verify a member’s eligibility:
• SC Medicaid Portal: https://portal.scmedicaid.com *
• Customer Care Center: 866-757-8286
• Availity Portal: https://www.availity.com *
• SCDHHS Medicaid Provider Service Center: 888-289-0709
* This link leads to a third-party site. That organization is solely responsible for the contents and privacy policies on its site.
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New identification card
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In addition to this ID card, members are required to carry their Healthy
Connections ID card.
Credentialing (cont.)
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Credentialing checklist
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Questions about credentialing?
To speak with an associate regarding credentialing application status,
you can call 800-868-2510, option 5
Please note the new email addresses for questions and credentialing
application submissions.
Email addresses:
• Initial enrollment applications: [email protected]
• Returning documentation: [email protected]
• Provider demographic updates: [email protected]
• Recredentialing: [email protected]
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M.D. Checkup
M.D. Checkup: provider validation
The electronic provider validation tool is available within My Insurance ManagerSM. This
feature allows you to verify your practice and physician demographic information
seamlessly. The information you provide is used to maintain our online provider
directories, which members use to find network participating primary care physicians,
specialists, hospitalists and medical suppliers. We also use the data you provide to
update your information in our systems to promote accurate claims processing.
You’ll have the opportunity to update information at any time; however, we require
verification for each location on a quarterly basis as follows:
January 1–March 31
April 1–June 30
July 1–September 30
October 1–December 31
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M.D. Checkup (cont.)
M.D. Checkup allows you to view information for all of the associated locations as well as the affiliated
practitioners for each location. The feature offers several transactions:
Verify – Information shown is current and accurate. Verify is the final step to confirming revisions and
attesting that no further action is needed for the quarterly verification.
Update – Once a change has been made, Update must be selected to confirm and accept the
change.
Remove Location – Enter or select a date to indicate that a location shown in the Location list is no
longer active or part of the organization.
Remove Practitioner – Enter or select a date to indicate that a practitioner is no longer participating
with the specific location.
Add Practitioner – Add a practitioner to the specific location by using the Add Practitioner search
function.
View and Edit – Access and edit location information (addresses, telephone number, fax number,
hours of operation, etc.).
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Cultural competency
Practices provide care for increasingly diverse populations. Because of
this diversity, understanding cultural differences is essential.
• Cultural competency is a set of congruent behaviors, attitudes and
policies that enable effective work in
cross-cultural situations.
• Cultural awareness is the ability to recognize the cultural factors,
norms, values, communication patterns/types, socioeconomic status
and world views that shape personal and professional behavior.
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Cultural competency skills
• Listens to others in an unbiased manner; respects other points of
view; promotes the expression of diverse opinions and perspectives
• Uses appropriate methods of interacting sensitively, effectively and
professionally with persons of all ages and lifestyle preferences from
diverse cultural, socioeconomic, educational, racial, ethnic and
professional backgrounds
• Recognizes the importance of the role cultural, social and behavioral
factors play in determining delivery methods for public health
services
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Cultural competency skills (cont.)
• Takes into account cultural differences when developing and adapting approaches to
problems
• Understands the dynamic forces contributing to cultural diversity
• Understands the importance of a diverse public health workforce
Obtain no-cost continuing medical education credits through further study of cultural
competency topics at https://www.thinkculturalhealth.hhs.gov/education *
Or
Review our cultural competency resources on our provider website:
• Cultural Competency and Patient Engagement training
• MyDiversePatients.com*
* This link leads to a third-party site. That organization is solely responsible for the
contents and privacy policies on its site.
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Fraud, waste and abuse
Providers are a vital part of the effort to prevent, detect and report Medicaid
noncompliance as well as possible fraud, waste and abuse.
• You are required to comply with all applicable statutory, regulatory and other
Medicaid managed care requirements in South Carolina, including adopting
and implementing an effective compliance program.
• You have a duty to Medicaid to report any violations of laws that you may be
aware of.
• You have a duty to follow your organization’s code of conduct that
articulates your commitment to standards of conduct and ethical rules of
behavior.
Visit www.HealthyBlueSC.com and select Providers to view more information
about fraud, waste and abuse.
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Reporting fraud, waste and abuse
• If you suspect it, report it to your Compliance department or your sponsor’s
Compliance department. The Compliance department will investigate and
make the proper determination.
• To report fraud, call the Healthy Blue confidential fraud hotline at
877-725-2702 or email [email protected].
• You may also call the South Carolina Department of Health and Human
Services fraud hotline at 888-364-3224 or email [email protected].
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BlueBlast
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Healthy Blue distributes a
monthly providers
newsletter called the
BlueBlast, which delivers
informative articles and
valuable updates to plan
processes.
Quality Department
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What is HEDIS?Healthcare Effectiveness Data and Information Set
HEDIS® is used to measure performance in the delivery of medical care and preventive health
services.
• HEDIS covers 81 measures across the following five domains of care:
– Effectiveness of care
– Access and availability of care
– Patient experience
– Utilization and relative resource use
– Health plan descriptive information
• HEDIS evaluates adherence to both physical and behavioral health Clinical Practice Guidelines
(CPG).
• HEDIS is one component of a larger accountability system and complements the NCQA
accreditation program.
• The HEDIS hybrid medical record review is completed annually from January to May. For the
review, a random sample of members are selected, and Healthy Blue requests medical records
from our providers.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
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How are members selected
for review?
• HEDIS:
– Annually: Members are randomly selected for review based on
a predetermined sample size identified for each measure. This
takes place during the annual data collection project performed
each spring.
– Year-round: Members who have not had a claim submitted for
specific services may be selected to assess barriers and provide
information to providers (Gaps in Care reports).
• Compliance audit:
– The Clinical Practice Consultant team pulls a stratified, random
sample of a provider’s panel for review of the medical record
documentation standards.
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HEDIS Measures Examples
Annual Well-Visits for Babies, Children, Adolescents
• Childhood and Adolescent Immunization
• Lead Screening
Comprehensive Diabetes Care
• Hemoglobin A1c
• Diabetic Eye Exam
• Blood Pressure
• Attention to Nephropathy
– Nephrology Referral, Prescription of ACE/ARB,
– Microalbumin or Urinalysis
Women's Health
• Prenatal and Postpartum Care
• Chlamydia Screening
• Breast and Cervical Cancer Screening
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Examples of HEDIS measures (cont.)
Behavior Health
• Antidepressant Medication Management
• Follow-Up for Children Prescribed ADHD Medication
• Follow-Up After Hospitalization for Mental Illness
• Use of First-line Psychosocial Care for Children and Adolescents on
Antipsychotics
• Metabolic Monitoring for Children and Adolescents on Antipsychotics
• Initiation and Engagement of Alcohol and Other Drug Dependence
Treatment
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Provider report cards
Provider report cards identify the following:
• Number of providers in the practice
• Total membership (current)
• Total gap members in the eligible population for HEDIS
• Number of target members needed to be seen to meet
the specific National Committee for Quality Assurance
(NCQA) percentile for that practice/for that measure
• Practice rate for that NCQA HEDIS measure
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Provider report card sample
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Care Opportunity Reports (formerly
Gaps in Care Reports)
Care Opportunity Reports include:
• Members who have not had any visits last year.
• Members who need preventive service(s).
• Current demographic information (Healthy Connections).
• Legend for each of the measures on the Care Opportunity Report.
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Care Opportunity Report sample
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CAHPS® power chart matrix – Adult
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CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).
CAHPS® Adult Survey Opportunities
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Medical records compliance audit
Medical records compliance audit (MRCA) starts during the
summer after HEDIS has ended.
• A contractual audit that reviews medical records for
documentation standards set by the state
• Audit locations with 200+ members
• Review five random records for up to five providers
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Quality practice consultant
territory map
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HEDIS questions:
Physical address:
Healthy Blue
Attn: Quality Department
4101 Percival Road, AX-E13
Columbia, SC 29229
Quality fax:
855-238-2257
Terry Pennington
803-834-0168
Terry Pennington
803-834-0168
Alfred Thomas, Jr.
803-391-2452
Contact information for the Quality
departmentIf you have questions, reach out to us. Quality is here to help!
For HEDIS-related questions or concerns, please contact
• Kim Chmiel at [email protected]
• Trish Whitehead at [email protected]
For Care Opportunity-related questions or concerns, please contact Devon Murphy at [email protected]
For Clinic Days information or questions, please contact Danetta Gibbs at [email protected]
To provide medical records for Care Opportunities during the HEDIS off season:
• Email records to [email protected]
• Fax records to 855-238-2257.
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Community outreach
Our community partnerships are just a few examples of the
ways we go above and beyond the provision of basic
health coverage.
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Marketing and outreach: coming to
a city near you
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Social media
Follow us on the following social media platforms:
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fb.me/HealthyBlueSC @CoachBlueSC @HealthyBlueSC
#Shininglightonthecommunity #HealthyBlueSC
Our focus
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Help people get the medical
care they need and the
respect they deserve.
Work with community and faith-based
organizations to help our members find local
resources.
Connect members to a strong network of primary care physicians and specialty
providers.
Continue to serve more
than 126,000 members
statewide.
Redetermination
We help members maintain health care coverage through
awareness:
• Renewing every 12 months from the date of enrollment.
• Making sure addresses are up to date with Healthy Connections if
the individual has moved.
• Reminding members to fill out the Healthy Connections Annual
Review Form completely and accurately, and send it back before the
due date given on the form.
We educate the community on ways to do this such as:
• Visiting https://www.scchoices.com * to make sure addresses are
up to date.
• Visiting the Healthy Connections office for other assistance.
* This link leads to a third-party site. That organization is solely responsible for the contents and privacy policies on its site.
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Extra benefits
• Free adult vision services (ages 21 and up)
– Annual eye exams
– Glasses and frames every two years
• Free GED ready assessment test (ages 17 and up)
• Free diapers (up to 15 months of age)
– Case of diapers (200 count)
– No more than six cases, after well-child visits
• Free diaper bags
• Free sports physicals
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Extra benefits (cont.)
• Free headphones (school-aged youth, K–5th grades)
• Free earbuds (school-aged youth, 6th–12th grades)
• Free Youth Explorer Program through Boy Scouts of America
– For youth, 3rd–12th grades
• Free Girl Scouts memberships
– For girls K–8th grades
• Discount on Boys & Girls Club fees (at participating clubs)
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Extra benefits (cont.)
• Free car seat
– Eligibility requirements apply
• Free Blue Book ClubSM
– Newborn to 26 months
• Community Resource Link
– Helps with finding low-cost, local service for:
• Housing
• Education
• Jobs
• And more
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Additional extra benefitsIn addition to the core benefits offered and the extra benefits described in
the previous slides, Healthy Blue also offers several other extra benefits:
• Free cellphone with monthly minutes data and texts
• Free circumcisions up to 1 year of age
• Free electric breast pump
• Free prenatal program
• Healthy Rewards reloadable gift card
• Free Internet Essentials program/free Wi-Fi for two months
• Free coupon booklet with discounts to local stores
• No copays for preventive/urgent care visits
• No copays for some over-the-counter drugs with a prescription
• Discounts for Jenny Craig®
• Free medication synchronization program for same-day medicine refills
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Healthy Blue
C.A.T. (Community Action Transit)
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Getting to your members to their health
care appointments can be hard. We can
take the hassle away by coordinating your
member’s transportation.
Call the Customer Care Center for more
information.
• 866-781-5094
• (TTY 866-773-9634 )
Meet Coach Bluesm
G.A.M.E. P.L.A.N. for health
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Get regular
check ups.
Always eat fruit
and veggies.
Make healthy
choices.
Exercise daily.
Play hard
and safe.
Learn ways to
be healthy.
Aim high
and set
goals.
Never give
up.
Coach Blue in the community
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Marketing/Outreach team
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Meet our teamPeedee region:
• Janasia Giles, Outreach Specialist Sr.
– Direct: 803-260-4782 /Email: [email protected]
Upstate region:
• David Rojas, Outreach Specialist Sr.
– Direct: 803-391-1299 /Email: [email protected]
Midlands region:
• Melody Clark, Outreach Specialist Sr.
– Direct: 803-683-1896 /Email: [email protected]
Lowcountry region:
• Deangelo Wesley, Outreach Specialist Sr.
– Direct: 803-394-1821 / Email: [email protected]
Midlands/PeeDee:
• Jermaine Tart, Outreach Care Specialist Sr.
– Direct: 803-683-0634 / Email: [email protected]
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Meet our team (cont.)
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Donna Williams, Marketing & Outreach Officer
• Direct: 803-260-6085
• Email: [email protected]
Letitia Lindsay, Community Outreach Manager
• Direct: 803-231-9138
• Email: [email protected]
Thank you for your participation
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www.HealthyBlueSC.comBlueChoice HealthPlan is an independent licensee of the Blue Cross and Blue Shield Association. BlueChoice HealthPlan has contracted with Amerigroup Partnership Plan, LLC, an independent company, for services to support administration of Healthy Connections.
IngenioRx, Inc. is an independent company providing pharmacy benefit management services on behalf of BlueChoice HealthPlan.
To report fraud, call our confidential Fraud Hotline at 877-725-2702. You may also call the South Carolina Department of Health and Human Services Fraud Hotline at 888-364-3224 or email [email protected].
BSCPEC-1558-19 January 2020