Provider Relations and Credentialing Updates
UPHP Provider
In-Service
October 25, 2023
Good
morning
and
welcome
!
Provider Relations &
Credentialing Updates
Sarah Dobson, Provider Relations Manager
CHAMPS Enrollment
•
Reminder: all providers and facilities must be enrolled in CHAMPS
•
Any questions regarding enrollment/reactivation:
ProviderEnrollment@Michigan.gov
1-800-292-2550
•
Reoccurring issue:
•
Members trying to fill prescriptions at pharmacies
•
Pharmacy declining refill
•
Check CHAMPS Enrollment
•
If the provider’s participation became inactive, will need to
be reactivated
CAQH Proview Provider Data
•
UPHP Credentialing Department has contracted with the Council
for Affordable Quality Healthcare (CAQH)
•
Now fully implemented
•
Collect provider data
•
Streamline credentialing
•
Eliminate as much paperwork and redundant processes as
possible
•
Credentialing Team has been able to access provider information
and collect updates via CAQH
•
Goal – Provider Relations Department to streamline the process
of collecting updates from CAQH
•
Download files – saves on provider outreach
Important MDHHS Links/Information
•
ListServ Email Notifications
Michigan Dept of Health & Human Services (govdelivery.com)
•
Bulletins
2023 Medicaid Policy Bulletins (michigan.gov)
•
Fee Schedule
Information Specific to Different Providers (michigan.gov)
•
MDHHS Provider Manual
MedicaidProviderManual.pdf (state.mi.us)
Medicaid Doula Benefit
•
Covered Services
•
A maximum of six total visits during the prenatal and postpartum
periods and one visit for attendance at labor and delivery will be
covered.
•
Additional visits may be requested by prior authorization
Doula - Provider Criteria
•
Doula must be:
•
At least 18 years of age
•
Possess a high school diploma or equivalent
•
Complete an MDHHS approved doula training program
•
MDHHS has assembled a Doula Advisory Counsel that will be comprised
of doulas and will be making future decisions about what programs are
to be added to the list of accepted programs.
•
Approved programs are on the doula initiative website
https://www.michigan.gov/Doula
Doula - Credentialing Requirements
•
Enroll in Community Health Automated Medicaid Processing
System (CHAMPS) for participation with Michigan Medicaid
•
Complete an approved doula training program
•
Be on the MDHHS Doula Registry
•
Professional liability insurance
•
Pass sanction screening checks
•
NPI and Tax ID/SSN to bill under
Doula – UPHP Contracting and Credentialing
•
Contact Provider Relations and request to contract
•
Contracting contact:
UPHPProviderRelations@uphp.com
•
Provider Relations will:
•
Collect provider information
•
Finalize a contract
•
Supply a credentialing application
•
Credentialing will process the application for enrollment into the
network
•
Credentialing contact:
Credentialing@uphp.com
Questions about member eligibility or number of visits available can
be directed to Customer Service at 906-225-7500.
Q
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o
n
s
?
Consumer Assessment of
Healthcare Providers and
Systems (CAHPS) Overview
Sarah Dobson, Provider Relations Manager
CAHPS Survey Overview
•
Consumer Assessment of Healthcare Providers and Systems (CAHPS)
•
Survey sent out to UPHP members annually
•
Experience with Provider Offices
•
Experience with Health Plan
•
Comprehensive results of survey are evaluated
•
Where are we excelling
•
Where can we improve
UPHP CAHPS Taskforce
•
Results reviewed by UPHP CAHPS Taskforce
•
Chief Operating Officer
•
Customer Service Manager
•
Credentialing Manager
•
Strategic Initiatives Manager
•
Clinical Coordinator – Quality Management
•
Provider Relations Manager
•
Government Programs Liaison
•
Review and implement activities and interventions on how to
improve CAHPS scores
Survey Questions – Provider Specific
Survey Questions – Provider Specific
Survey Questions – Provider Specific
CAHPS Score Trends 2020-2023
CAHPS Score Trends 2020-2023
CAHPS Score Trends 2020-2023
CAHPS Survey Overview
•
Different factors can affect scores
•
Response rates
•
How many members completed each year
•
How often members received care
•
Interventions from the CAHPS Taskforce
•
More educational information to provide to provider offices
•
Social media
•
Provider network review
Q
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o
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s
?
Best Practices: Pharmacy
and Medical Pharmacy
Prior Authorizations
Rachael Prusi, PharmD, MSGH
Director of Pharmacy
Objectives
24
•
Medicaid and Medicare Part D Formulary Pages
•
How to use the Searchable Formulary
•
Prior Authorization/Coverage Determination Forms
•
Request for Information
•
Medicaid – Carve Out Information
•
Cover My Meds for PA
•
Medical Pharmacy
www.uphp.com
25
www.uphp.com
- Pharmacy Tab
26
Medicaid Formulary
27
1
2
3
28
Searchable Formulary
PA Criteria: Click on PA Button
29
Medicare Formulary
30
1
2
3
4
Provider Forms
31
1
3
2
4
32
Page 1 of 5
33
Magellan’s Request for Additional Information
When you receive a “Notice of Prior Authorization Determination” it
is important to respond in a timely manner.
The request is asking for additional information to make a clinical
determination.
The patient information and medication you requested are included
on the notice.
Return this form to Magellan at the listed fax number to
facilitate completion of your prior authorization request.
34
https://michigan.magellanrx.com/provider/
•
The Michigan Preferred Drug List – Summary Document will list
drugs that are carve outs.
•
Drugs that are carve outs mean the authorization and coverage is
through MDHHS.
•
A pharmacy would bill FFS at point of sate even though
the member is a UPHP member.
Contact FFS MagellanRx (prior authorization): 1-877-864-
9014
35
Medicaid – Carve Out Information
Cover My Meds
36
Cover My Meds
37
Medicaid Medical Pharmacy
Prior Authorization
•
Medical Pharmacy Drugs are drugs that are administered in a
healthcare setting (J Codes, Q Codes, etc)
•
Authorization for these codes must be obtained before services are
rendered
•
Retrospective requests will not be reviewed
•
Authorization for out of network rendering providers
must be obtained prior to review of medical pharmacy
requests
38
Medicaid Medical Pharmacy
Prior Authorization
•
A prior authorization is NOT required for medications
administered during:
Emergency room visits
Observation room setting
DRG related payment for inpatient admissions
Requests can be submitted via the provider
Requests can be submitted via the provider
portal!
portal!
39
Take Aways
Take Aways
•
Use the UPHP online formularies
•
Call with questions
•
Respond to requests for information in a timely
manner
•
Use CoverMyMeds at your own risk
•
Medical pharmacy requests can be submitted
via the portal
40
Medical Director and Pharmacy Department
Medical Director
Michael Mlsna, MD
Pharmacists
Rachael Prusi, PharmD, MSGH, UPHP Pharmacy Director
Don Moisio, PharmD, RPh
Abby Wales, PharmD
Pharmacy Assistants
Nadine Hatch
Chris Nelson
UPHP Pharmacy 906-232-1628
41
Q
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i
o
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?
10 Minute
Break
Cotiviti Provider
Intelligence
Supporting
Redeterimination
Lindsey Havel, BSN, RN
Clinical Services Manager – Quality Management
Redetermination
The Michigan Department of Health and Human Services (MDHHS)
must annually re-determine if members continue to be eligible for
Medicaid benefits. This is called redetermination, or renewal.
During the Public Health Emergency (PHE), the annual review was
paused. It will now resume on a monthly rotation.
Redetermination month will be the same month that benefits became
effective.
The redetermination process includes a full review of all areas that
determine member eligibility for benefits.
UPHP
– Medicaid Renewals: link for members to MIBridges to update
contact information!
Medicaid Renewals Infographic
– print and hand out this resource to your
Michigan Medicaid members!
Medicaid Renewal Infographic
Cotivti Provider Intelligence
UPHP offers all primary care provider clinics a web-
based population health management tool called
Cotiviti
Provider Intelligence.
Provider
Intelligence combines Cotiviti’s:
Industry-leading risk adjustment and predictive modeling
Evidence-based clinical quality rules
H
ealthcare utilization metrics
C
laims-based HEDIS measures
to enable payers and providers to manage risk and target
opportunities for improving healthcare results. Users can easily
stratify and segment populations, access member-level detail (e.g.,
conditions, comorbidities, clinical events, gaps in care, prescription
compliance), and evaluate efficiency.
How To find Redetermination Date in Cotivti
How To find Redetermination Date in Cotivti
How To find Redetermination Date in Cotivti
How To find Redetermination Date in Cotivti
How To find Redetermination Date in Cotivti
How To find Redetermination Date in Cotivti
How To find Redetermination Date in Cotivti
HEDIS Care Gap View
HEDIS Care Gap View
HEDIS Care Gap View
HEDIS Care Gap View
HEDIS Care Gap View
Quality or HEDIS Questions?
Teresa Mager
tmager@uphp.com
Q
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?
Medicaid Benefits
Monitoring Program
(BMP)
Patty Cornish, RN, MSN
Clinical Coordinator – Utilization Management
Purpose of the BMP
•
Promote quality health care
•
Promote patient safety through the reduction of drug interactions
and/or possible drug abuse, and duplication of medical services
•
Identify members whose utilization patterns appear to reflect
overutilization and/or misuse of their Medicaid benefits
•
Analyze individual member’s health service utilization data
•
Improve member utilization of Medicaid services through
educational contacts and monitoring
•
Improve the continuity of care and service coordination to prevent
fragmentation of services
Purpose of the BMP, Continued…
•
Assure that members are receiving health care services which are
medically necessary and supported by evidenced-based practices,
thereby curtailing unnecessary costs to the program.
•
Designed to steer the member back to the PCP for care
coordination and appropriate medical management
BMP Enrollment Criteria
•
Fraud – The member is suspected or has been convicted of fraud
in the use of Medicaid benefits
•
Misuse of Emergency Department Services
•
The member is noted to have any of the following utilization
•
More than 3 ED visits in 1 quarter
•
Repeat ED visits with no follow-up with a primary provider or specialist,
when appropriate
•
More than 1 ED facility used in one quarter
•
Repeated ED visits for non-emergent reasons
BMP Enrollment Criteria, Continued…
•
Misuse of Pharmacy Services
•
Utilizing more than 3 pharmacies in 1 quarter
•
Member has concerning utilization patterns for controlled
medications over a 1-year period
•
Member is obtaining more than 5 RXs for controlled meds in 1
quarter
•
Is using multiple prescribers for controlled meds
•
May include providers who provide RXs for controlled meds in the
following situations
•
Member pays cash for the office visit while using the Medicaid benefit to pay
for the controlled RXs
•
Member pays cash for controlled meds RXs from providers not approved by
the primary care provider
BMP Enrollment Criteria, Continued…
•
Misuse of Physician Services
•
Member is using more than one physician/physician extender in
different practices to obtain duplicate or similar services for the same
or similar health care services and/or to obtain RXs for controlled
meds.
•
Is using covered services to obtain RXs for meds that are subject to
abuse and paying cash for these meds.
UPHP’s Three Step Enrollment Process
•
Step 1 – BMP Letter of Concern
•
The member with concerning utilization is sent a BMP letter of
Concern explaining where the member is meeting BMP enrollment
criteria.
•
The member has 12 days to respond.
•
UPHP will use care coordination to help the member if there are
identified barriers to care.
Three Step Enrollment Process, Continued…
•
Step 2 – BMP Enrollment Letter
•
If the member does not respond to the letter of concern or voices no
intent to improve utilization that member will be enrolled in the
BMP.
•
The member has 12 days to respond and designate a primary
provider, a pharmacy and any specialists involved in their care.
Three Step Enrollment Process, Continued…
•
Step 3 – BMP Provider Assignment Letter
•
Sent 12 days after the enrollment letter is sent.
•
This letter is mailed to the member identifying and locking that
member into a primary provider and a pharmacy.
•
Those lock-in assignments will be effective 12 days from the date the
provider assignment letter is mailed.
BMP Enrollment
•
BMP enrollment lasts a minimum of 2 years
•
If member utilization remains a concern the BMP enrollment can
continue indefinitely.
•
BMP is a statewide Medicaid program
•
If the member moves to lower Michigan, the member is still in the
BMP.
•
Member cannot change PCP assignment
•
Exceptions for PCP assignment change
•
The assigned PCP decides to dismiss the member from that primary
practice.
•
The member moves out of the geographic area served by the PCP.
BMP and Controlled Medications
•
These meds are
only
paid for by UPHP if prescribed by the PCP or
a provider approved by PCP.
•
PCPs are
not expected
to prescribe controlled meds.
•
Referrals for specialty care/pain management where controlled meds
may be prescribed are a decision made by the PCP and
will be
supported by UPHP
.
•
ED RXs for controlled meds are
not paid
for by UPHP.
•
Visits to any provider outside of the PCP office cannot be paid for
unless the referral comes from the PCP office.
•
A UPHP PA is needed
and generally approved for 1 year to lessen
PCP paperwork.
BMP Prior Authorization Exemptions
•
ED services (BMP members are
never told
they cannot use the
ED and all ED claims are paid
except RX’s for controlled
meds
)
•
Dental Services
•
DME services
•
Services rendered in a skilled nursing facility
•
Hospice services
•
Vision services
•
Health Department services
•
Hearing services
•
Podiatry services
•
Chiropractic services
•
Services by a non-prescribing BH provider
•
Women’s health care: OB/GYN, STI screening and treatment, etc.
Role of UPHP BMP Clinical Coordinator
•
Ongoing review of member utilization
•
Enrollment process into the BMP
•
All BMP letters sent by the BMP Coordinator
•
Facilitator of care coordination issues between PCP, other
providers and the BMP member.
•
The goal is to enhance communication by all parties
involved in member’s treat plan
.
Role of UPHP BMP Clinical Coordinator, Continued…
•
Ongoing education with BMP members and providers
•
To help the member understand that ED services provide episodic
care that is not able to move that member’s health issues toward
resolution or stability.
•
To remind providers that BMP guidelines are
not meant to dictate
care
, and
instead supports the PCP and specialists in their treatment
plan to optimize member’s health care outcomes.
BMP Support for the PCP Office
•
Quarterly reimbursement to the PCP office
•
Recognition of the additional coordination BMP members require
•
Increase in time spent to manage this member
•
Time spent completing PAs for all referrals, including in network
providers
Is your patient in the BMP?
•
Office staff can check CHAMPS
•
Recommend checking at the time of appointment registration
•
There is a BMP indicator on the right side of the screen in CHAMPS
•
If that indicator says “Yes” click to view assigned providers
•
BMP PCP
•
BMP Pharmacy
Do you have a patient that would benefit from the BMP?
•
Members must have Medicaid or Healthy Michigan.
•
Call UPHP (906-225-7500) and ask to speak to the BMP
Coordinator to start the process.
Patty Cornish, RN, MSN
UPHP BMP Clinical Coordinator –
Utilization Management
P: 906-225-7791
F: 906-225-8779
pcornish@uphp.com
Q
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Provider Satisfaction
Survey Results
Sarah Dobson, Provider Relations Manager
Provider Satisfaction Survey
•
Each year UPHP conducts a Provider Satisfaction Survey
•
Information obtained allows UPHP to measure how well we are
meeting our provider’s expectations and needs
•
Plan’s strengths
•
Areas of opportunity for improvement
•
Three stages of data collection
•
•
•
Phone (final attempt)
•
Reviewed by UPHP’s Service Advisory Committee
Provider
Satisfaction
Survey
Provider
Satisfaction
Survey
Provider
Satisfaction
Survey
Provider
Satisfaction
Survey
Opportunity to provide comments/concerns/feedback
•
Most mentioned from 2023 survey
•
Reimbursement rates low
•
UPHP follows the Michigan Medicaid Fee Schedule rates
•
MDHHS notification of rate increase
2343-Practitioner-P.pdf (govdelivery.com)
•
UPHP working on Value Based Payment options
•
Timely communication of changes (rates, codes, etc)
•
Bi-Monthly Provider Newsletter
•
Please reach out to UPHP Provider Relations to verify you receive these
notifications
•
uphpproviderrelations@uphp.com
•
Past notifications:
https://www.uphp.com/providers/provider-resources/
•
Ad-hoc communication
Opportunity to provide comments/concerns/feedback
•
Lack of specialists within area
•
Network under constant review
•
Amount of no-show appointments
•
Transportation Cards
•
Providers wishing to request cards can email
uphpproviderrelations@uphp.com
or call 906-226-4285
•
Transportation Mileage Reimbursement
•
https://www.uphp.com/transportation/
•
Develop a website for Benefit Verification
•
UPHP Assist Provider Portal
Q
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UPHP Assist Provider
Portal Overview
Krystina Gwinn – Customer Service Manager
Lisa Geyser – Business Systems Manager
Rachael Prusi – Director of Pharmacy
Agenda
•
Benefits of Registering for the portal
•
Eligibility and Benefits
•
Accumulators
•
Claims
•
Prior Authorization
•
Member Portal
•
Registration and Utilization Stats
•
Provider Registration
UPHP Assist- Providers
•
Soft Launch: April 2023
•
Live: August 1, 2023
•
Top features in the secure portal are:
•
View current and historical UPHP coverage for members
•
View member claim details
•
View member benefit accumulators
•
View member ID card
•
View and submit prior authorizations
•
Medical (Office/Outpatient, Surgery, Home Health Care, Genetics testing)
•
DME
•
Medicaid Medical Pharmacy
•
Message UPHP Staff
•
assist.uphp.com
•
Provider User Guide
Home Page
Eligibility and Benefits
Eligibility and Benefits
Accumulators
Accumulators
Member ID Card
Claims
Claims
Prior Authorization
New Prior Authorization
Confirm Member
Requestor Information
Authorization Type
Office and Outpatient - Authorization Details
Office and Outpatient - Authorization Details
Office and Outpatient - Rendering Provider
Details
Office and Outpatient – Confirmation
Status Prior Authorizations
Status Prior Authorizations
Utilization Management - Reminders
•
Surgery Prior Authorizations
•
This is only for those procedures that require prior authorization by
UPHP such as panniculectomy, mammoplasty, and gender-affirming
surgery.
•
Skilled Nursing and Inpatient notifications are still received via
fax
•
Easily check the status of the prior authorization in the UPHP
Assist portal. No longer need to call to status prior authorization.
•
Use Provider User Guide
•
Call UPHP Utilization Management for any questions
•
906-225-7774
UPHP Medicaid Medical Pharmacy Prior
Authorizations
www.uphp.com
Medical Pharmacy Prior Authorization
•
Similar, Pick out the drug, and the drug information. Similar level
of detail, and dig in deeper.
•
Rachel to add slides
Medical Pharmacy – PA Request
Medical Pharmacy – Drug/Dx Information
Medical Pharmacy – Dosing Information
Medical Pharmacy – Verify Request
Medical Pharmacy – Rendering Provider
Medical Pharmacy – Supporting Documents
Medical Pharmacy Requests Status
Medical Pharmacy Request Reminders
•
Reference prior authorization criteria to understand exactly what
information to include (
www.uphp.com
> Pharmacy > Medicaid
Medical Drug Benefit)
•
Standard requests: 14 days, Expedited/Urgent: 72 hours
•
Referring and Rendering providers can both see authorization
information in the portal
•
If no OON authorization, the request will not be processed
•
If the current authorization is valid for >30 days from the new
request, the new request will not be processed
•
Please respond to requests for information in a timely
manner
UPHP Assist- Members
•
Live since February 2023
•
Benefits of the member portal
•
View, print and request member ID cards
•
View current assigned Primary Care Provider (PCP)
•
Request a PCP change
•
View current and past UPHP eligibility
•
View medical and pharmacy claims
•
View the status of mileage reimbursement
•
View benefit accumulators
•
Message UPHP staff
•
MHL only:
•
View their Care Plan
•
Message their UPHP Care Manager
•
assist.uphp.com
•
Member User Guide
Registration and Usage Stats
•
Members Registered: 1,145
•
Providers Registered: 590
•
Prior Authorizations Entered: 939
•
Register providers and office staff at https://assist.uphp.com
•
Registration requests are reviewed in 1-3 business days
•
UPHP Claims Portal
•
UPHP Assist is not replacing the UPHP Claims Portal
•
UPHP Help Desk: 906-225-6811
•
Registration and technical questions
Questions?
Krystina Gwinn
Customer Service Manager
Upper Peninsula Health Plan
kgwinn@uphp.com
Lisa Geyser
Business Systems Manager
Upper Peninsula Health Plan
lgeyser@uphp.com
Rachael Prusi
Director of Pharmacy
Upper Peninsula Health Plan
rprusi@uphp.com
PowerPoint Presentation
UPHP Website
•
www.uphp.com
•
Provider Training
•
Provider-Inservice
CHAMPS Enrollment reminder for all providers and facilities, with instructions provided for reactivation if necessary. The UPHP Credentialing Department has implemented CAQH ProView to streamline credentialing processes, reducing paperwork. Important MDHHS links are shared for notifications and information. Details on the Medicaid Doula Benefit covered services and provider criteria are outlined for reference.
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Presentation Transcript
UPHP Provider In-Service October 25, 2023
Provider Relations & Credentialing Updates Sarah Dobson, Provider Relations Manager
CHAMPS Enrollment Reminder: all providers and facilities must be enrolled in CHAMPS Any questions regarding enrollment/reactivation: ProviderEnrollment@Michigan.gov 1-800-292-2550 Reoccurring issue: Members trying to fill prescriptions at pharmacies Pharmacy declining refill Check CHAMPS Enrollment If the provider s participation became inactive, will need to be reactivated
CAQH Proview Provider Data UPHP Credentialing Department has contracted with the Council for Affordable Quality Healthcare (CAQH) Now fully implemented Collect provider data Streamline credentialing Eliminate as much paperwork and redundant processes as possible Credentialing Team has been able to access provider information and collect updates via CAQH Goal Provider Relations Department to streamline the process of collecting updates from CAQH Download files saves on provider outreach
Important MDHHS Links/Information ListServ Email Notifications Michigan Dept of Health & Human Services (govdelivery.com) Bulletins 2023 Medicaid Policy Bulletins (michigan.gov) Fee Schedule Information Specific to Different Providers (michigan.gov) MDHHS Provider Manual MedicaidProviderManual.pdf (state.mi.us)
Medicaid Doula Benefit Covered Services A maximum of six total visits during the prenatal and postpartum periods and one visit for attendance at labor and delivery will be covered. Additional visits may be requested by prior authorization
Doula - Provider Criteria Doula must be: At least 18 years of age Possess a high school diploma or equivalent Complete an MDHHS approved doula training program MDHHS has assembled a Doula Advisory Counsel that will be comprised of doulas and will be making future decisions about what programs are to be added to the list of accepted programs. Approved programs are on the doula initiative website https://www.michigan.gov/Doula
Doula - Credentialing Requirements Enroll in Community Health Automated Medicaid Processing System (CHAMPS) for participation with Michigan Medicaid Complete an approved doula training program Be on the MDHHS Doula Registry Professional liability insurance Pass sanction screening checks NPI and Tax ID/SSN to bill under
Doula UPHP Contracting and Credentialing Contact Provider Relations and request to contract Contracting contact: UPHPProviderRelations@uphp.com Provider Relations will: Collect provider information Finalize a contract Supply a credentialing application Credentialing will process the application for enrollment into the network Credentialing contact: Credentialing@uphp.com Questions about member eligibility or number of visits available can be directed to Customer Service at 906-225-7500.
Consumer Assessment of Healthcare Providers and Systems (CAHPS) Overview Sarah Dobson, Provider Relations Manager
CAHPS Survey Overview Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey sent out to UPHP members annually Experience with Provider Offices Experience with Health Plan Comprehensive results of survey are evaluated Where are we excelling Where can we improve
UPHP CAHPS Taskforce Results reviewed by UPHP CAHPS Taskforce Chief Operating Officer Customer Service Manager Credentialing Manager Strategic Initiatives Manager Clinical Coordinator Quality Management Provider Relations Manager Government Programs Liaison Review and implement activities and interventions on how to improve CAHPS scores
CAHPS Survey Overview Different factors can affect scores Response rates How many members completed each year How often members received care Interventions from the CAHPS Taskforce More educational information to provide to provider offices Social media Provider network review
Best Practices: Pharmacy and Medical Pharmacy Prior Authorizations Rachael Prusi, PharmD, MSGH Director of Pharmacy
Objectives Medicaid and Medicare Part D Formulary Pages How to use the Searchable Formulary Prior Authorization/Coverage Determination Forms Request for Information Medicaid Carve Out Information Cover My Meds for PA Medical Pharmacy 24
www.uphp.com 25
Medicaid Formulary 1 2 3 27
Medicare Formulary 1 2 3 4 30
Provider Forms 1 3 2 4 31
Page 1 of 5 33
Magellans Request for Additional Information When you receive a Notice of Prior Authorization Determination it is important to respond in a timely manner. The request is asking for additional information to make a clinical determination. The patient information and medication you requested are included on the notice. Return this form to Magellan at the listed fax number to facilitate completion of your prior authorization request. 34
Medicaid Carve Out Information https://michigan.magellanrx.com/provider/ The Michigan Preferred Drug List Summary Document will list drugs that are carve outs. Drugs that are carve outs mean the authorization and coverage is through MDHHS. A pharmacy would bill FFS at point of sate even though the member is a UPHP member. Contact FFS MagellanRx (prior authorization): 1-877-864- 9014 35
Medicaid Medical Pharmacy Prior Authorization Medical Pharmacy Drugs are drugs that are administered in a healthcare setting (J Codes, Q Codes, etc) Authorization for these codes must be obtained before services are rendered Retrospective requests will not be reviewed Authorization for out of network rendering providers must be obtained prior to review of medical pharmacy requests 38
Medicaid Medical Pharmacy Prior Authorization A prior authorization is NOT required for medications administered during: Emergency room visits Observation room setting DRG related payment for inpatient admissions Requests can be submitted via the provider portal! 39
Take Aways Use the UPHP online formularies Call with questions Respond to requests for information in a timely manner Use CoverMyMeds at your own risk Medical pharmacy requests can be submitted via the portal 40
Medical Director and Pharmacy Department Medical Director Pharmacists Pharmacy Assistants Nadine Hatch Chris Nelson Michael Mlsna, MD Rachael Prusi, PharmD, MSGH, UPHP Pharmacy Director Don Moisio, PharmD, RPh Abby Wales, PharmD UPHP Pharmacy 906-232-1628 41
10 Minute Break
Cotiviti Provider Intelligence Supporting Redeterimination Lindsey Havel, BSN, RN Clinical Services Manager Quality Management
Redetermination The Michigan Department of Health and Human Services (MDHHS) must annually re-determine if members continue to be eligible for Medicaid benefits. This is called redetermination, or renewal. During the Public Health Emergency (PHE), the annual review was paused. It will now resume on a monthly rotation. Redetermination month will be the same month that benefits became effective. The redetermination process includes a full review of all areas that determine member eligibility for benefits. UPHP Medicaid Renewals: link for members to MIBridges to update contact information! Medicaid Renewals Infographic print and hand out this resource to your Michigan Medicaid members!
Cotivti Provider Intelligence UPHP offers all primary care provider clinics a web- based population health management tool called Cotiviti Provider Intelligence. Provider Intelligence combines Cotiviti s: Industry-leading risk adjustment and predictive modeling Evidence-based clinical quality rules Healthcare utilization metrics Claims-based HEDIS measures to enable payers and providers to manage risk and target opportunities for improving healthcare results. Users can easily stratify and segment populations, access member-level detail (e.g., conditions, comorbidities, clinical events, gaps in care, prescription compliance), and evaluate efficiency.
