Provider News - June 2018

REQUIREMENTS: (1) IMMEDIATELY: Notify medical records department to prepare for upcoming RADV audit kick-off memo from CMS and Security Health Plan regarding ACA plan members. Establish process to provide source medical record documentation for selected enrollees within requested timeframe to ensure member coverage validation. (2) IMMEDIATELY: Update billing workflows to remove maternity admission notification requirement for Security Health Plan members when hospital stay is within federally mandated timeframes (48 hours post-vaginal delivery, 96 hours post-cesarean section). Continues to require notification only if stay exceeds allowed timeframe per inpatient hospital authorization requirements. (3) By October 1, 2018: Billing team must update prior authorization system and Magellan Rx processing to require prior auth for the following specialty drugs: Aldurazyme (J0342), Cerezyme (J1399), Elaprase (J1561), Elelyso (J1562), Lumizyme (J1565), Naglazyme (J1567), Vpriv (J1575), Bavencio (J9227), Cuvitru (J1100), Sustol (J1100), and Tecentriq (J9308). Update prior authorization request workflows in provider portal at provider.securityhealth.org. Providers must submit prior auth requests before dispensing these medications or claims will be denied. (4) ONGOING: Providers and billing staff must review and implement EHR documentation practices to avoid 'cloning' violations: do not copy entire notes; edit all defaulted data; document visit-specific history of present illness; update patient history; use only relevant review of systems for current visit; base exam findings on specific date of service; ensure assessment and plan reflect problems addressed that day. Non-compliant documentation may result in audit findings, payment recoupment, or compliance violations.