Thewww.partnershealth.comProhibited ContractsOur Medicare Choice contractscontain a provision that outlinesthat you must maintain goodstanding with Medicare toparticipate in our PARTNERSM C Provider Network. Mostof our providers understand thatthis relates to whether or not theprovider has been sanctioned orexcluded from the MedicareProgram. It has come to ourattention that some providerswere not aware that if they electto opt out of Medicare, thisaffects their ability to participatein our PARTNERSMedicare Choice ProviderNetwork, which is separate fromour commercial network.The purpose of this article is toremind you of your obligation toinform us if your status withMedicare changes, includingsanctions, limitations, exclusionsas well as your decision to optout of the Medicare Program.The PARTNERSMedicare Choice plan is part ofthe Medicare Program, and assuch PARTNERS can not usefunds from the Medicareprogram to pay opt outproviders for services renderedto it’s M C enrollees.According to regulation 42 CFR422.206, "an M C organizationmay not pay, directly orindirectly, on any basis, forservices (other than emergencyor urgently needed services asdefined in §422.2) furnished to aMedicare enrollee by aphysician (as defined in section1861(r)(1) of the Act) or otherpractitioner (as defined insection 1842(b)(18)(C) of theAct) who has filed with theMedicare carrier an affidavitpromising to furnish Medicarecovered services to Medicarebeneficiaries only throughprivate contracts under section1802(b) of the Act with thebeneficiaries. An M Corganization must pay foremergency or urgently neededservices furnished by aphysician or practitioner whohas not signed a private contractwith the beneficiary."We will monitor compliancewith this regulation throughfeedback with CIGNA, the localMedicare Carrier, on a timelybasis. If any payments are madeto you during a period when wewere not aware of your opt outstatus, we will request refundsof those payments. To preventthis situation, please advise usof your plans to opt out prior toyour opt out effective date inaccord with your contract withus.For additional informationregarding Private Contracts andthe Opt Out process refer to theCMS website bltin/1997/sr97-2/forall/private contracts questions and answers.htmlFall 2003 IssueProhibited ContractsPARTNERS M C OutpatientTherapy Service Enhancementto Traditional MedicareReminder NoticeInfluenza / Pneumococcal VaccinationCodesPARTNERS Authorization GuidelineChangesPARTNERS Authorization GuidelinesRadConsult ProgramStep-by-Step Description of theRadconsult ProcessSample Radiology Request FormMedical Coverage Policy UpdatesNetwork Management Field OfficesCentral Office Telephone & Fax Nos.Mailing Address for Claims
PARTNERS M C OutpatientTherapy Service Enhancementto Traditional MedicareOn June 10, 2003 CMS released aProgram Memorandum (CMSPub. 60AB, Trans. No. AB-03085) regarding the" Implementation of OutpatientTherapy Service Limitations."The memorandum was released toadvise Medicare Fee-for-Serviceproviders of CMS’ intent to limitoutpatient physical therapy andspeech-language pathology(combined) to 1,590. In additionCMS will impose a 1,590 limiton occupational therapy services.These limitations are for servicesReminderNoticePlease remember that as ofJanuary 1, 2004 all PARTNERSmembership will terminateEXCEPT PARTNERSMedicare Choice. If a nonMedicare Choice patientpresents a PARTNERS ID cardfor services after January 1,2004, please ask for currentinsurance coverage information.It is always appropriate to ask tosee a patient’s ID card at everyvisit. With many insurancesrenewing and changing benefitsin January it is even moreimportant to verify coverage andinsurance company information.Please submit claims for datesof service in 2003 as quickly aspossible. The 180 day timelyfiling deadline still applies tomembers who are covered undera different carrier in 2004.2rendered during the period ofSeptember 1, 2003 to December31, 2003. The limitation isconsistent with outpatientrehabilitation service limitationsof the past (most recently 1999).As with all benefits, PARTNERSMedicare Choice has the option toeither match or enhanceMedicare’s base benefit.PARTNERS has, for many years,opted to enhance Medicare’sOutpatient Therapy benefit by notimposing a dollar limitation.Influenza PneumococcalVaccinationCodesInfluenza vaccinations should bereported using the sA revised copy is included inthis newsletter for yourreference. There were threechanges as noted below:DELETIONS: BRCA1 and BRCA2 nolonger requires prior approvalADDITIONS: Surgical Treatment forMorbid Obesity KyphoplastyPlease note:Endoluminal radiofrequencyablation therapy has been addedto the PARTNERS MedicalPolicy as a treatment forvaricose veins. All treatment forvaricose veins requires priorreview for medical necessity.Adult Influenza VaccineCPT 90659 for theInfluenza vaccineHCPCS G0008 for theadministration of theInfluenza vaccinePediatric Influenza VaccineCPT 90657, 90658 or newCPT 90655Pneumococcal vaccinationsCPT 90732 for thePneumovax vaccineHCPCS G0009 for theadministration of PneumovaxThis newsletter, unless otherwise stated,applies to both Commercial and MedicareChoice members.PARTNERS is committed to offering its healthplans on a non-discriminatory basis.PARTNERS does not discriminate based on color,religion, national origin, age, race,disability, handicap, gender, or healthstatus as defined by CMS.PARTNERS National Health Plans ofNorth Carolina, Inc.Provider Services336-774-5400 or 1-888-296-9790Fall 2003
PARTNERS National Health Plans of North Carolina, Inc. Prior Authorization Guidelines Cosmetic Procedures (or those potentially cosmetic), such as but not limited to:4Abdominoplasty4Blepharoplasty4Breast Reduction4Genioplasty/Sliding Osteotomy4Rhinoplasty4Strabismus Surgery (for members 12 years or older)Dental Services for Accidental InjuryDiagnostic Testing4Neuropsychological Testing4Psychological Evaluations for medical reasonsDurable Medical Equipment and Prosthetics4All Rental Items4Items 600.00 (Purchase)4Penile ImplantsExternal CounterpulsationHome Health Agency ServicesHospiceHyperbaric O2 TherapyInpatient Admissions*4Scheduled admissions, including acute hospital, rehabilitation facility, hospice and skilled nursing facility4NOTE: For urgent/emergency admits (including obstetric admits), prior authorization is NOT required. However, notification to PARTNERS ofurgent/emergency admits (including obstetric admits) within 24 hour or the first business day after the admission is required.Investigational Procedures (or those potentially investigational)Nonparticipating Providers and ServicesPharmaceuticals (See also PARTNERS formulary)4Amevive back4Cardiac Rehabilitation4Pulmonary Rehabilitation4Speech Therapy4Wound Care ClinicSurgery4Capsulotomy (laser)4Extracapsular cataract extraction with intraocular lens4Lithotripsy, Extracorporeal for Orthopedic Problems (plantar fasciitis and chronic lateral epicondylitis are the two conditions considered forcoverage)4MOHS Surgery4Refractive Surgical Procedures4Retina, central photocoagulation (laser)4Pan-retinal photocoagulation (PRP, laser)4Photodynamic Therapy with Visudyne4Spinal Neurostimulators4Surgical Treatment of Morbid Obesity4Surgical Treatment of Sleep Apnea4Temporomandibular Joint Surgery4Transplants, Bone Marrow and Organ4Varicose Vein Treatment4Vertebroplasty and Kyphoplasty, Percutaneous (Medicare Choice Only; Not Covered for Commercial Members)Transportation (non-emergency)* Members using Alternate Out-of -Plan Benefits would require Prior ApprovalEffective: 10/1/2003
RadConsult ProgramThe Radiology Scheduling Line(RSL) program is now requiredfor PARTNERS (non-RJR)Medicare Choice members only.HealthHelp operates the RSL,through which orderingphysicians schedule certainnonemergent outpatientradiology procedures to ensurethat quality, cost-efficientradiology providers are utilized.In addition to the RSL program,HealthHelp implemented itsRadConsult program forPARTNERS (non-RJR)Medicare Choice members onFebruary 1, 2003. The orderingphysician will continue to beresponsible for obtaining atracking number fromHealthHelp’s RSL–RadConsult.Imaging facility personnelshould continue to ask for thetracking number beforescheduling the procedure.RadConsult is HealthHelp’s callcenter capability that providesreal-time decision support forphysicians who order imagingprocedures such as CT and MRI.RadConsult identifiesopportunities for physician-to-physician consultation. TheRadConsult program is designedto help in choosing theappropriate test if a test isnecessary. Like all HealthHelpprograms, RadConsult focuseson decreasing PARTNERSMedicare Choice members’exposure to unnecessaryradiation.If you have questions,please contact HealthHelp’sRSL–RadConsult representative,Carmela Nayve, at(888) 835-4464 [email protected] DESCRIPTION OF THERADCONSULT PROCESS:PARTNERS Tracking Number:Ordering physicians areresponsible for obtaining atracking number for all CT andMRI studies throughRadConsult. The radiologyfacility will submit the trackingnumber to PARTNERS with theclaim.4. The patient is scheduled atparticipating facility.Request resulting ineducational consult:6. A HealthHelp radiologistcontacts the orderingphysician to discuss theordered procedure.Standard request:1. The ordering provider’s officecalls RSL department viatelephone.7. The ordering provider decideswhat procedure will beperformed.2. For CT and MRI studies,demographic information isprovided to a HealthHelprepresentative.8. The patient is scheduled at aparticipating facility.1. The ordering provider’soffice calls RSL department(888) 835-4464.2. For CT and MRI studies,demographic information isprovided to a HealthHelprepresentative.3. The representative askssystem-generated questions.45. Via fax, the orderingprovider’s office is notifiedof the appointment’s dateand time.3. The representative askssystem-generated questions.5. The clinical coordinatorcontacts the physician’s officefor more clinical information.the test is scheduled (or)9. Via fax, the orderingprovider’s office is notifiedof the appointment’s dateand time.4. The requested procedure issent to a RadConsult clinicalcoordinator for review.Fall 2003
RADIOLOGY REQUEST FORMAll procedures listed need Reference Numbers.Patient’s Name D.O.B. WeightPARTNERS ID# Employer Group #Home Phone # ( ) Work Phone # ( ) Patient’s Zip CodeWho do you want to be called? Patient Other Name and Phone #Ordering Physician Ordering Physician’s Signature (not required)Ordering Physician Fax ( ) Ordering Physician’s Phone # ( )Diagnosis/Symptoms (No “Rule Out”)Radiology Facility RequestedPlace of Service Out-Patient ER 23 HOUR STAYSTAT Yes NoPreop Yes NoAppointment is Scheduled: Date Time LocationSpecial Instructions (i.e., member sent as walk-in):Reference #MEDICALQUESTIONSPatient has a history of the following: (Check those that apply) Any Metal In The Body Any Allergies To Contrast Material Any Previous Films To Area Being Scanned Is The Patient Claustrophobic Has The Patient Had Surgery To The Area Being Scanned Pacemaker HX of CancerFLUOROSCOPY Esophagram UGI UGI w/Small Bowel Small Bowel Series Barium Enema Voiding Cystogram IVPBUN CREATBUN CREAT IVP w/Tomography OtherULTRASOUND Rt. Upper Quadrant Single Organ Gallbladder Single Organ Pancreas Single Organ Kidney Single Organ Aorta Complete Abdominal Complete Retroperitoneal Pelvis Prostate Testicular Sono Breast Sono Fetal Age Thyroid Bone Scan Whole Bone Scan LTD Flow Thyroid Scan Only Thyroid Uptake w/Scan Liver/Spleen Scan Hida Scan Renogram/ERFP Scan Other Head Sinus Series Sinus Limited Upper Extremity R Lower Extremity R Chest/ Thorax Abdomen Pelvis XRT Plan Cervical Spine Thoracic Spine Lumbar Spine Other Head Cervical Spine Thoracic Spine Lumbar Spine Upper Extremity R Lower Extremity R Dexa QCTNUCLEARMEDICINECT Without Contrast With ContrastBUN CREATMRI Without Contrast With ContrastBUN CREATBONEDENSITYPETOTHERLLLL Knee Shoulder AbdomenRRLLRRLL Trans Vaginal Venous Doppler-Upper Venous Doppler-Lower Other MRA / Head MRA / Neck Other Other RADIOLOGY SCHEDULING: 1-888-835-4464FAX: 1-888-863-4464When completed, please retain as a part of patient record.Rev. 8/01
Medical Coverage Policy UpdatesThe following medical coverage policies have been updated and approved by the PARTNERSPhysician Advisory Group:PolicyMajor ChangesAdditional NotesChelation TherapyDigitalis toxicity andarrhythmias added asindications for coverage Criteria for nonapprovalexpandedChemical PeelLimited to: Photos no longer required6 peels within 6 monthsDental Services Due toAccidental InjuryName changed to:Dental Services Due toInjury Removed limitation oftreatment beyond post-injuryperiodDental HospitalizationName changed to: DentalHospital or Outpatient orAmbulatory Surgery Center Criteria for approvalexpanded in accordancewith NC State LegislativeStatutesVaricose Vein TreatmentEndoluminal RadiofrequencyAblation added to coverageapproval with Medicare guidelinesVertebroplastyNames changed to: Vertebroplasty/Kyphoplasty Percutaneous Required conservative therapyprior to procedures reduced to6 weeks.Kyphoplasty is covered whenMedicare criteria are met.If you have questions regarding the PARTNERS policies or wish to obtain a copy please contact your NetworkRepresentative.The Pharmacy ConnectionChanges for 2003Additions to the PARTNERS formulary effective October 2003: Crestor Emend FinaceaDeletions to the PARTNERS formulary effective January 1, 2004: Celebrex Bextra FML ForteBenefit Exclusions from the PARTNERS formulary effectiveJanuary 1, 2004:Beginning January 1, 2004, Prilosec and omeprazole will no longerbe covered under the pharmacy benefit.New Benefit for PARTNERS Medicare Choice Members EffectiveJanuary 1, 2004:PARTNERS Medicare Choice (PMC) Members participating withPMC through the individual plan will pay a 15.00 copayment forcovered generic drugs, subject to PARTNERS formulary andcoverage limitations. These drugs will be identified for providers inthe 2004 PARTNERS formulary.6Fall 2003
Network Management Field OfficesOfficePhoneFaxAddressCharlotte(704) 561-2740(704) 676-0501PO Box 35209Charlotte, NC 28235Greensboro(336) 316-5374(336) 316-02592303 W. Meadowview Rd.,Ste. 200Greensboro, NC 27407Greenville(252) 758-4745(252) 752-6705PO Box 1447Greenville, NC 27835OfficePhoneFaxAddressHickory(877) 889-0002(828) 431-3155PO Box 1588Hickory, NC 28601Raleigh(919) 469-6935(919) 469-69092501 Aerial Center DriveSuite 225Morrisville, NC 27560Wilmington(877) 889-0001(910) 509-38222005 Eastwood RoadSuite 201Wilmington, NC 28403PARTNERS Central Office Telephone andFax Numbers:Telephone Numbers:800-942-5695 or 336-760-4822 (General Information)888-296-9790 or 336-774-5400 (Provider Information Line)888-310-4110 (PARTNERS Medicare Choice Customer Service)336-774-5412 (PARTNERS Disease Management)Fax Numbers:Claims: 336-659-2962Referrals: 336-659-2944Customer Services: 336-659-2963Health Services: 336-794-1556 (Utilization Review/Precertification)336-659-2945 (Case Management)336-794-1546 (Disease Management)Mailing Addresses for ClaimsPHYSICIAN Claims Address:PARTNERS National Health Plans of NC, Inc.P.O. Box 17268Winston-Salem, NC 27116-7268FACILITY Claims Address:PARTNERS National Health Plans of NC, Inc.P.O. Box 17368Winston-Salem, NC 27116-7368Fall 20037
RadConsult Program physician consultation. The RadConsult program is designed to help in choosing the appropriate test if a test is necessary. Like all HealthHelp programs, RadConsult focuses on decreasing PARTNERS Medicare Choice members' exposure to unnecessary radiation. If you have questions, please contact HealthHelp's RSL-RadConsult .