Hogar Provider News & Updates – March 2021

Provider News & Updates – March 2021

Well-care Visits for Adolescents

The American Academy of Pediatrics and Bright Futures recommend annual well-care visits during adolescence. Studies have shown that adolescence is one of the most dramatic periods of human growth and development, second only to infancy. While this age group is generally characterized by good health, adolescence is a key transition period that requires a unique set of health care services.

Intercommunity Health Network Coordinated Care Organization (IHN-CCO) has a quality initiative focused on increasing adolescent well-care visits each year. To support this initiative IHN-CCO will be sending an adolescent well-care visit postcard reminder this spring and fall to its adolescent population if they have not had a PCP visit in the past year.

Help us reach our goal by continuing your health maintenance reminder calls and mailings. Schedule IHN-CCO members for their well-care visits when they call and consider how the well-care visits can be incorporated into other visits, like sick-care visits and sports physicals.

Providing Care With the Prioritized List

What is the Prioritized List and How Is It Used?
The Oregon Health Plan’s (OHP) Listado priorizado de servicios de salud is a list of diagnosis and treatment pairings that IHN-CCO uses to determine if a diagnosis and/or service is considered to be part of the OHP benefit package. The Oregon Health Services Commission (HSC) designs and maintains the prioritized list under the direction of the Oregon Legislature, who determines the level to which the list will be funded. Diagnoses and/or treatments that are considered below the line are not funded by the available budget set forth by the Oregon Legislature and are therefore not considered part of the OHP benefit package.

How is the Prioritized List Determined?
Currently, the prioritized list includes 662 line items consisting of condition/treatment pairs. The Oregon Legislature approved funding for lines one to 471 of the prioritized list for Jan. 1, 2020, and will remain at this level through Dec. 31, 2021. Services on the approved lines are covered for IHN-CCO and OHP Plus members, with some vision and dental services subject to exclusion for adults ages 21 and over. ICD-10-CM diagnosis codes, CPT and healthcare common procedure coding system (HCPCS) codes define the condition/treatment pairs that make up each line. This system places a high emphasis on preventive services and chronic disease management, with the idea that using these services will reduce more expensive and often less-effective treatments in the crisis stages of disease. The ranking of health services reflects the best unbiased information available on clinical effectiveness and cost-effectiveness, and the values of Oregonians.

Additional Resources for Providers
For OHA policies related to prioritized list coverage or exclusions see the General Rules, Oregon Health Plan Rules and Provider Guidelines whether a specific procedure is potentially covered according to the prioritized list, providers can access the HSC List Inquiry on the Medicaid Provider Web Portal, or call the OHP Code Pairing and Prioritized List hotline at 800-393-9855 o 503-945-5939 (Salem).

Time to Register for March Provider Webinar!

Samaritan Health Plans’ Provider Relations staff invites you to  the first quarter provider webinar. Please choose from one of the following dates:

  • Tues., March 9, 2 to 3 p.m.
  • Wed., March 10, 9 to 10 a.m.

Get important plan updates that include information on:

  • COVID-19.
  • Traditional health care workers.
  • Intensive care coordination.
  • Prioritized list and more.

Join us for plan updates and have an opportunity to ask questions.

Introducing Surescripts for Electronic Prior Authorizations

Samaritan Health Plans is implementing electronic prior authorization services for medication dispensing with Surescripts in March 2021. This will be a free service for providers who have access through their integrated EHR or through the Surescripts provider portal. Surescripts ePA is designed to give clinicians and staff more time to focus on quality patient care without the administrative burden of manual prior authorizations. This saves users valuable time by eliminating the forms, faxes and phone calls associated with submitting prior authorizations. For more information on how to register and navigate Surescripts, please read the Surescripts Prior Authorization Guide.

Intensive Care Coordination

Intensive care coordination is a specialized care management program for members on IHN-CCO and who may have special health care needs or are part of a prioritized population. Examples include:

  • Older adults, individuals who are hard of hearing, deaf, blind or have other disabilities.
  • Members with complex or high health care needs: multiple or chronic conditions, SPMI or are receiving Medicaid-funded long-term care services and supports.
  • Children ages 0 to 5: showing early signs of social/emotional or behavioral problems.
  • Members with a serious emotional disorder diagnosis.
  • Members in medication assisted treatment for substance use disorder.
  • Women who have been diagnosed with a high-risk pregnancy.
  • Children with neonatal abstinence syndrome.
  • Children in Child Welfare.
  • IV drug users who have SUD and who need withdrawal management.
  • Members who have HIV/AIDS.
  • Members who have tuberculosis.
  • Veterans and their families.
  • Members at risk of first episode psychosis and individuals within the intellectual and developmental disability populations.

Intensive care coordination services may include assistance to ensure timely access to providers: coordination of care to ensure consideration is given to unique needs; assistance to providers with coordination of services and discharge planning; coordination of community support such as social services.

Members are identified through direct referrals from contracted providers, community partners directly engaged with the member, referrals from utilization management, data analysis and member representatives.

Care management staff are assigned to support the member in developing an individualized care plan. This may begin by completing a health assessment. The care plan is created by and for the member to positively impact health outcomes. The care plan addresses the member’s clinical and social needs identified during the assessment or from the member and tracks the members identified goals and process to overcome barriers identified. The care plan is supported by the members interdisciplinary care team. The team consists of internal and external health professionals and social supports working together to coordinate the member’s care. The care team coordinates care and develops a plan of care for high-needs members.

The member’s PCP is responsible for developing a treatment plan for the member with the member’s participation. The treatment plan should be in accordance with any applicable state quality assurance and utilization review standards.

Interested members and providers should complete the Formulario de recomendación de miembros para gestión de casos y enviarlo al equipo de Gestión de Casos. Fax a 541-768-9768 o envíe un correo electrónico seguro a [email protected]. Members in an eligible plan can agree to opt-out of the program when contacted by the Care Management department.

Get to Know the Samaritan Health Plans’ Care Team

The primary focus of the Care Management program is to ensure that appropriate, effective and high-quality care is provided to members by offering support, navigation and care coordination. This vital program consists of the following professionals who ensure members receive medically appropriate evidence-based care at the appropriate level:

Nurse clinical care managers are responsible for coordinating care in cooperation with the PCP and other providers; documenting care information and actions taken; developing an individualized care plan with the member; coordinating with member’s care team and community resources; educating members as appropriate about member conditions, procedures and treatments and appropriate use of plan resources.

Behavioral health care managers are required to possess a clinical/professional degree. The behavioral health care manager provides screening, knowledge of criteria and clinical judgment to assess patient needs and assure that medically appropriate treatment is provided in a quality, cost-effective manner within the benefit plan of the member. They participate in care coordination and transition planning for members receiving mental health services and collaborate with community partners to identify member needs, support service delivery and help close gaps in members’ care. They also support community efforts in establishing the youth and family system of care and initiatives aimed at improving access to services and quality of care.Trabajadores de salud comunitarios work in collaboration with the clinical care team and community partners. They assist members in accessing health care by connecting members to their PCP and helping them understand their health plan benefits, limits and guidelines. They also are integral in coordinating community supports and resources to reduce the barriers imposed by social determinants of health.

How to Contact Care Management

Contact us by phone:
De lunes a viernes, 8 a m a 8 p m.
541-768-5207 o llame gratis al 888-435-2396

Contact us by mail:
Samaritan Health Plans
PO Box 1310, Corvallis, OR 97339
Email the SHP Care Team
[email protected]

Reminders & Notices From SHP

Cambios demográficos y de proveedores

To update demographic information, add or terminate a provider or change panel availability, see our provider forms at samhealthplans.org/Actualización.

Acreditación

Remember to allow 90 days from the time we receive a completed Oregon Practitioner Credentialing Application and supporting documents for the Credentialing Department to complete its new practitioner process.

Electronic Corrected Claims

Una reclamación corregida es cualquier reclamación que tenga un cambio en una reclamación procesada previamente (por ejemplo, cambios o correcciones en cargos, códigos de procedimientos o diagnósticos, fechas de servicio, líneas agregadas, etc.). Las correcciones de reclamaciones enviadas electrónicamente deben enviarse en el siguiente formato:

1.  In the 2300 Loop, the CLM segment (claim information), CLM05-3 (claim frequency type code) must indicate
7” – REPLACEMENT (Replacement of Prior Claim).

2.  In the 2300 Loop, a REF*F8 segment needs to follow the CLM segment (Claim Information) and must include the prior claim number issued by Samaritan Health Plans or IHN-CCO for the claim being corrected. Samaritan Health Plans and IHN-CCO claim numbers consist of 11 to 12 numeric characters and can be found on your electronic remittance advice (EDI 835), paper remittance advice or in the Provider Connect portal.

3.  Any original claim lines that are removed and not resubmitted on the replacement claim will automatically be removed during reprocessing and the previously paid amount will be auto recouped from the next payment issued.

Trabajadores de salud tradicionales

Don’t forget that traditional health workers can provide an important service to care for our IHN-CCO members. If you are interested in learning more about services available and how to integrate them into a member’s care plan, visit the IHN-CCO website to learn more about Trabajadores de salud tradicionales.

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