Connection supplemental articles and policies - January 2007

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Connection - January 2007 (pdf, 450 KB)

supplemental articles

• improving our referral process
• quit to win—successfully
• formulary updates

policies and forms

• Claims auditing software
• Clinical trials payment policy
• Durable medical equipment-capped rental payment policy
• Emergency department payment policy
• Evaluation and management payment policy
• Infertility/assisted reproductive technology (ART) services payment policy
• Inpatient medical review and payment policy
• Physician-owned diagnostic imaging center payment policy
• Preoperative autologous blood donation payment policy
• Registered nurse first assistant (RNFA) payment policy
• Units of service edit payment policy

improving our referral process

Fallon Community Health Plan has changed its referral process—for the better! Now, all PCPs will need to do is give the specialist physician their FCHP vendor ID number—and the specialist will include that number on the submitted claim. That will be our evidence of a referral. PCPs no longer need to contact us. They will work directly with the specialists to expedite services for their patients.

For an overview of the referral process and details for PCPs and chiropractors, please see the January 2007 print version of Connection.

services requiring preauthorization
All services currently requiring preauthorization will continue to require preauthorization from FCHP. These include services with out-of-product, tertiary, noncontracted and/or Peace of Mind Program^TM providers or facilities. The following services require preauthorization for HMO and POS members.

• All elective inpatient admissions
• All services with out-of-product, tertiary, noncontracted and/or Peace of Mind Program providers or facilities
• All unlisted CPT-4 and unspecified HCPCS codes
• Specified DME and prosthetics and orthotics
• Elective hospital/facility same-day surgery and ambulatory procedures identified on the procedure codes list
• Genetic testing
• Home health services
• Infertility/assisted reproductive technology
• Neuropsychological testing
• Nonemergent ambulance service
• Office-based procedures identified on the procedure codes list
• Oral surgery services and treatment
• Oxygen
• PET scans
• Plastic/reconstructive surgery and treatment
• Transplant evaluation

preauthorization procedure
The preauthorization procedure does not change. To contact our Care Services Department with questions related to preauthorization, please call 866-ASK-FCHP, press 3.

• The requesting provider submits a request via the Online Referral Tool or completes the required sections of the request for preauthorization form, which will be available on www.fchp.org in January 2007.
• If using the request for authorization form, it should be faxed to Care Review at 508-368-9700.
• FCHP will send a determination to the requesting provider, PCP and member. The status will also be available via the Online Referral Tool.
• Please note that FCHP will not process retroactive plan preauthorizations.
• PPO members are responsible for notifying FCHP of certain procedures, or a penalty may be applied.

quit to win—successfully

You know the statistics. Lung cancer, predominantly caused by smoking, is the leading cause of cancer death in the United States for both men and women. And, according to all estimates, smoking-related medical costs are in the billions. You can help your patients who smoke by advising them to quit.

Fallon Community Health Plan offers a tobacco treatment program, called Quit to Win, to help anyone to develop a stop-smoking plan that’s right for them and give them the tools they need to succeed.

We are thrilled to report that participants in Quit to Win have achieved a one-year abstinence rate of 32%. That’s more than double the rate that the National Cancer Institute considers “successful,” and is among the highest in the nation.

Group sessions are free (you don’t have to be an FCHP member to join us), and FCHP members can buy nicotine patches at a greatly discounted rate. We have several locations in Central Mass: Auburn, Leominster, Milford, Spencer and Worcester. Phone counseling is an option for FCHP members who cannot attend our group sessions. FCHP MassHealth members receive everything free.

Patients can call us directly to enroll at 508-368-9540 or 888-807-2908. If you would like a free poster for your exam rooms, please call us.

formulary updates

Fallon Community Health Plan has made several changes to its commercial plan formulary, including changing prior authorization requirements and adding new medications. Please see the changes below.

commercial plan formulary

additions

changes

moratorium*

Cesamet^® (nabilone)
Fentora^® (fentanyl) buccal tablet
Januvia^® (sitagliptin)
Noxafil^® (posaconazole)
Vectibix^® (panitumumab)
Zolinza^® (vorinostat)

* FCHP’s Moratorium Policy was enacted to ensure patient safety and to allow for adequate time for the development, review and approval of clinical criteria. When a new medication first becomes available, it will fall under this policy and be excluded from coverage. A process is in place that allows for the quick review of provider requests for noncovered pharmaceuticals.