NOVEMBER 2020 The RightCare Update
the Right Care updateWinter 20161theN OV E M B E R 2 02 0RightCare updateRightCarean an n ua l p ub l i c at i o n fo r pa r ti ci pati n g p rovi d e rs fo r Right Careback to topRCSWHP 10203
the Right Care update20201Table of Contentsp2Multiple Medicaid COVID-19 Flexibilities Extensionp2Provider Demographic Changesp3COVID-19 Telehealth and Telemedicinep6Expecting the Best Maternity Case Management Programp8Extended Ophthalmoscopyp9Hurricane Laura Informationp9Affirmative Statement About Incentivesp10Complex Case Managementp11Provider Directory Accuracyp12TMHP Requires Providers to Revalidate Enrollmentp13Formulary Information and Pharmaceutical management Proceduresp14Services Needing Approval on the Medical Benefitp15Appointment Availabilityp16Value-added Servicesp17Representative Territory Mapp18Disease and Condition Managementp19Healthy Texas Women Needs New Providersback to top
the Right Care update20202Multiple Medicaid COVID-19 FlexibilitiesExtended Through November 30, 2020The following Medicaid and Children’s Health Insurance Plan (CHIP) flexibilities have beenextended through November 30, 2020, unless the U.S. Secretary of Health and HumanServices ends the public health emergency earlier. If the public health emergency endsearlier, HHSC will provide additional information. “Correction to ‘COVID-19 Guidance:Targeted Case Management ThroughRemote Delivery’” “Waiver Extension for DMECertification and Receipt Form” “Claims for Telephone (Audio-Only)Behavioral Health Services” “Claims for Telephone (Audio-Only)Medical Services” “FQHC Reimbursement forTelemedicine (Physician-Delivered)and Telehealth (Non-PhysicianDelivered) Services” “RHC Reimbursement forTelemedicine and Telehealth Services” “SHARS Services Provided ThroughTelemedicine or Telehealth” “Claims for Telehealth Service forOccupational, Physical, and SpeechTherapy” “Claims for Telephone (Audio-Only)Early Childhood InterventionSpecialized Skills Training” “Claims for Telephone (Audio-Only)Nutritional Counseling Services” “Texas Health Steps CheckupGuidance Extended ThroughJuly 31, 2020”For more information, call the TMHP ContactCenter at 1-800-925-9126Provider Demographic ChangesProviders should notify RightCare (SWHP) when there are changes to their practice, such as: Change of ownership and taxidentification number (TIN). Change of address (service/mailing/billing), phone number, or fax number. New provider added to group orpractice. Provider terminations from group orpractice. Adverse actions impactingpractitioner’s ability to provide services. Termination from or opting out ofparticipation in Medicare or Medicaid.All changes reported should include an effective date.To access the on line tools to report these changes, visit https://rightcare.swhp.org/en-us/prov/forms-tools and choose, complete, and submit the appropriate form.Providers should also make sure those changes are reflected in their TMHP enrollment. Notdoing so will cause claims to deny.back to TOC
the Right Care update20203COVID-19 Telehealth and TelemedicineThe Policy below covers all lines of business.Scott and White Health Plan (SWHP), and all wholly owned subsidiaries including FirstCare HealthPlans (FirstCare), monitors policy changes from the Centers for Medicare & Medicaid Services(CMS), the federal government and the Texas State Legislature pertaining to the Coronavirus(COVID-19). Please check the SWHP.org and FirstCare.com websites frequently as any newguidance or information will be updated as it becomes available.PRIOR AUTHORIZATION: Not applicable. (see websites for PA updates)Effective March 6, 2020, SWHP and FirstCare has expanded telehealth and telemedicineservices and reimbursement for ALL contracted providers across ALL lines of businessincluding Commercial and Government Programs (i.e. Medicare Advantage, DSNP,Medicaid STAR and CHIP).Providers Impacted: All SWHP or FirstCare contracted medical, behavioral, and mental health providers All eligible in-network medical providers who have the ability and desire to connect withtheir patients through synchronous virtual care (live video-conferencing) orasynchronous care (non-video care such as online or telephonic) to performTelemedicine (Physician Delivered) or Telehealth (NON-Physician delivered) arepermitted to do so. Exclusions – Public-facing platforms (Tik Tok, twitch, Facebook Live, etc.) Visit HHS.gov for more information on allowed/excluded platforms Member cost-sharing (copay) is waived for Telehealth/Telemedicine visits. Member cost-sharing (copay) is waived for COVID-19 testing.Exclusions: Regulator Limitations CMS - Medicare and Exchange Health and Human ServicesCommission – Medicaid and CHIP TDI - Commercial State GovernmentTimeframe:This expanded provider telehealthand telemedicine access is effectiveimmediately, for Dates of Service(DOS) March 6, 2020 forward, untilfurther notification by the Health Planas deemed by Regulatory Entities.Member Eligibility:This policy change applies toMembers whose benefit plans covertelehealth and telemedicine services.cont’d next pageback to TOC
the Right Care update20204Reimbursement and Correct Coding:Scott and White Health Plan will compensate providers at 100% of the allowable amount asspecified in the provider’s agreement or fee schedule for telehealth or telemedicine serviceswithout Member share of cost reduction to the provider’s payment.This applies for all diagnoses and is not specific to a COVID-19 diagnosis for all telehealth ortelemedicine services during the specified (see list of codes in policy at https://swhp.org/enus/prov/home-with-news) This is intended to accommodate “social distancing” for Memberswho require medical care. Medical, Behavioral, and Mental Health Providers: For the time period specified above,services listed in the (see list of codes in policy at https://swhp.org/en-us/prov/home-withnews) are covered and reimbursable under this policy. Documentation requirements for a telehealth/telemedicine services are the same as thoserequired for any face-to-face encounter, with the addition of the following: A statement that the service was provided using telemedicine or telephonic consultation;cor r ect co d i n g :Commercial Plans (including Self Insured Groups and High Deductible Plans) Effective dates of service (DOS) March 6, 2020 forward, until further notification by theHealth Plan as deemed by Regulatory Entities. Any originating site requirements that may apply are waived for telehealth and telemedicineservices provided via a real-time audio and/or video communication system and arereimbursable. Place of Service for telehealth/telemedicine services: “02” Telehealth (per CPT guidelines)OR the place of Service (POS) equal to what it would have been had the service beenfurnished in-person (per CMS guidelines). SWHP will reimburse telehealth and telemedicine services, which are on the list of CMSapproved telehealth services and/or published by the AMA in Appendix P of 2020 CPT , andappended with modifier “95”, modifier “GT” for Critical Access Hospital Method II providers,modifier “GQ” for services furnished as part of a federal telemedicine demonstration projectin Alaska and Hawaii using asynchronous (store and forward) technology, and modifier “G0”for services furnished for diagnosis and treatment of an acute stroke Face-to-Face visits for non-COVID-19 related diagnosis will continue to have a Member shareof cost assessed, and the Member is responsible to pay the provider their share of cost. Refer to COVID-19 Billing Reference in policy at https://swhp.org/en-us/prov/home-withnews for specific ICD-10 Diagnosis coding requirement related to Face-to-Face COVID-19visits (Non-telehealth/telemedicine delivery).Medicaid STAR & CHIP Plans As directed by HHSC. Telephonic (audio-only) medical (physician-delivered) evaluation and management servicesare eligible for reimbursement for dates of services from March 20, 2020. Place of Service for telephonic/telehealth/telemedicine services: “02” telehealth for mostprovider types; “50” for FQHCs and “72” for RHCs. SWHP will reimburse telephonic, telehealth, and telemedicine services, which arerecognized by HHSC and appended with modifier 95. Refer to COVID-19 Billing Reference in policy at https://swhp.org/en-us/prov/home-withnews for specific ICD-10 Diagnosis coding requirement related to Face-to-Face COVID-19cont’d next pageback to TOC
the Right Care update20205visits (Non- telephonic/telehealth/telemedicine delivery). Telephonic evaluation and management services are not to be billed if clinical decisionmaking dictates a need to see the patient for an in-person or telemedicine (video) officevisit within 24 hours or at the next available appointment. In those circumstances, thetelephone service shall be considered a part of the subsequent office visit. If the telephonecall follows an office visit performed and reported within the past seven calendar days forthe same diagnosis, then the telephone services are considered part of the previous officevisit and are not separately billed. Specific Codes payable as telephonic, telehealth or telemedicine under Texas Medicaid andCHIP programs can be found at http://www.tmhp.com/Pages/Medicaid/Medicaid home.aspx.Medicare Advantage including DualEligible Special Needs Plans Effective dates of service (DOS) March6, 2020 forward, until further notificationby the Health Plan as deemed byRegulatory Entities. Any originating site requirements thatmay apply under Original Medicare arewaived for telehealth and telemedicineservices provided via a real-time audioand/or video communication systemand are reimbursable. Place of Service for telehealth/telemedicine services should besubmitted with the Place of Service(POS) equal to what it would have beenhad the service been furnished inperson. SWHP will reimburse telehealth andtelemedicine services, which arerecognized by CMS and appended withmodifier “95”, modifier “GT” for CriticalAccess Hospital Method II providers,modifier “GQ” for services furnishedas part of a federal telemedicinedemonstration project in Alaska andHawaii using asynchronous (store and forward) technology, and modifier “G0” for servicesfurnished for diagnosis and treatment of an acute stroke (refer to COVID-19 Billing Referencein policy at https://swhp.org/en-us/prov/home-with-news for definition of modifiers). Face-to-Face visits for non-COVID-19 related diagnosis will continue to have a Member shareof cost assessed, and the Member is responsible to pay the provider their share of cost. Refer to COVID-19 Billing Reference in policy at https://swhp.org/en-us/prov/home-withnews for specific ICD-10 Diagnosis coding requirement related to Face-to-Face COVID-19visits (Non-telehealth/telemedicine delivery). Specific Codes payable as telehealth or telemedicine under Medicare Advantage can befound at CMS.gov.back to TOC
the Right Care update20206Expecting the Best Maternity Case Management ProgramOur History and Our New In-House Maternity Case Management TeamScott and White Health Plan (SWHP) is pleased to offer our RightCare Membersthe Expecting the Best Maternity Case Management Program, focused on helpingexpectant mothers enjoy a healthy pregnancy. This Case Management teamhas a broad range of experience with maternal and neonatal medicine, lactationconsultation, social work and community health.Serving Our Members and ProvidersOur maternity case managers are dedicated to supporting your patient and yourplan of care throughout pregnancy and after homegoing. Members enrolled in ourprogram have direct access to a maternity RN Case Manager or Care Navigator andreceive one on one assistance with the team member throughout their pregnancy.cont’d next pageback to TOC
the Right Care update20207We can help by: coordinating community support assistance for social determinants of healthneeds; providing in-home support for serious complications of pregnancy,such as hyperemesis gravidarum, gestational diabetes, and pregnancy-inducedhypertension, helping to avoid hospitalizations. This in-home nursing support isdelivered as a value added services through home healthcare. helping to coordinate transportation for medical appointments; screening for depression during and after their pregnancy, then helping arrangefor behavioral health support, such as counseling; providing education and guidance on post-delivery warning signs; and providing care coordination and educational support to mom and baby for a yearafter delivery.Members are encouraged to enroll in the Text4baby app or the Baylor Scott and WhiteMaternity feature on the MyBSWHealth app. These apps provide members with memberswith educational pregnancy notifications to help them have a healthy pregnancy.How to Refer Your PatientsWe want to serve your team to help meetthe needs for our members. All Scottand White Health Plan Members whoare pregnant are eligible to enroll in thisprogram. Please reach out to us if we canhelp you or if you would like to refer one ofyour patients to this program. Call the customer service numberon the back of your patient’s healthinsurance card; or Email our team atHPmaternitycasemanagement@bswhealth.org. Please provide:patient’s name, member number,patient’s phone number, expecteddue date/gestational age, and reasonfor the referral.back to TOC
the Right Care update20208Requests for ExtendedOphthalmoscopyAccording to the American Academy of Pediatrics (AAP)’s2018 guidance Screening Examination of Premature Infantsfor Retinopathy of Prematurity, infants born premature orwith low birth weight are at risk for developing retinopathyof prematurity (ROP). Because of the usually predictableand sequential nature of ROP progression, and the provenbenefits of timely treatment in reducing the risk of visionloss, efficacious care now requires that infants who are atrisk receive carefully timed retinal examinations to identifytreatment-requiring ROP in time for that treatment to beeffective.Texas Medicaid Vision Services policy currently limitscoverage of ophthalmoscopy (procedure codes 92201 and92202) to two services per year. With evidence of medicalnecessity, additional screening examinations of prematureinfants for retinopathy of prematurity must be consideredthrough the Texas Health Steps-Comprehensive CareProgram (CCP).Texas Health Steps-CCP is an expansion of the EarlyPeriodic Screening, Diagnosis, and Treatment serviceas mandated by the Omnibus Budget Reconciliation Actof 1989, which requires states to provide all medicallynecessary treatment for correction of physical or mentalhealth conditions to Texas Health Steps-eligible clients(birth through 20 years of age) when federal financialparticipation (FFP) is available.Prior authorization of CCP services is required and maybe requested in writing by completing the appropriaterequest form, attaching any necessary supportivedocumentation, and submitting them by mail, fax, or theelectronic portal to the TMHP-CCP department. For clientsenrolled in managed care, providers should refer to theclient’s specific MCO for prior authorization details.Additional information on Texas Health Steps-CCP isavailable in the Texas Medicaid Provider ProceduresManual, Children’s Services Handbook, Section 2, “MedicaidChildren’s Services Comprehensive Care Program (CCP).”For more information, call the TMHP Contact Center at800-925-9126.back to TOC
the Right Care update20209Hurricane Laura InformationTexas providers rendering servicesto evacuees from Louisiana due toHurricane Laura may complete theHurricane Emergency ExpeditedApplication with Louisiana Medicaidto receive reimbursement forservices rendered to LouisianaMedicaid clients for the fee-forservice program.If providing care to a Louisianamanaged care enrollee, providerswill need to contact the clients’managed care organization (MCO)in order to be reimbursed forservices provided. Refer to theHealthy Louisiana Hurricane LauraProvider Assistance FrequentlyAsked Questions (FAQ) documentfor MCO credentialing contactinformation.Answers 1, 2, and 11 of the Louisiana FAQare specific to enrollment and eligibilityverification: Louisiana Departmentof Health Informational Bulletin 2017 August 30, 2020: Hurricane LauraProvider Assistance FAQsLouisiana Medicaid Resources Louisiana Medicaid ProviderEnrollment Louisiana Medicaid Provider & PlanResources (Managed CareInformation) Louisiana Department of HealthInformational Bulletin 20-17August 30, 2020: Hurricane LauraProvider Assistance FAQsFor more information, call the TMHPContact Center at 800-925-9126.Affirmative StatementAbout IncentivesRightCare does not use incentives toencourage barriers to care and services,specifically reward those conductingutilization review for denying coverage,or provide financial incentives for UMdecision makers to make decisionsthat result in underutilization. Utilizationdecisions are based only on theappropriateness of care and theexistence of coverage.back to TOC
the Right Care update202010Complex Case ManagementSWHP has Case Managers available to help support you in your plan of care with yourpatients who are members of Scott and White Health Plan. Ways we can help are: Teaching and reinforcing self-management for the patient’s condition; Helping Members arrange for health care services; Arranging for community resources and working through social service needs, even whenthe Member has reached the limits of what his/her health insurance plan covers; and Helping Members find an adult Primary Care Physician when a child transitions to anadult age.SWHP also identifies Members for participation in complex case management and carecoordination by following patients through hospital stays and by examining claims forconditions or care patterns likely to benefit from the support of a Case Manager.To refer a patient for Case Management, email CASEMANAGEMENT@BSWHealth.orgor call SWHP Customer Service at 1-888-316-7947 or 1-844-655-5200 TTY 711. You mayalso reach us by sending a fax to (800) 626-3042. This is an at no cost service for ourMembers, who may opt-in or opt-out of this program at any time. Find out more e-coordination-philosophy-andgoals.cont’d next pageback to TOC
the Right Care update202011P rov i d e r D i re c to r y Ac c u ra cyWhen RightCare members are looking for anin-network physician/provider, they use ouronline provider search tool. The RightCaredirectory allows members to search fordoctors, hospitals, and other medical providersin their area.It is critical that the information in the providerdirectory is current and accurate. Please takethe time to go to our website at https://portal.swhp.org/#/ and review your formstools, so that we can update your informationand have it reflected accurately in our providerdirectory.The Provider Information Change Form allowsyou to update information for your practicelocation, billing address, mailing address,or even add an additional location to yourcontract.If you find inaccurate information, such asaddress or phone number, please complete theappropriate demographic form located atback to TOC
the Right Care update202012TMHP Requires Providers to RevalidateEnrollmentReminder: Providers must complete their revalidation enrollment at TMHP before the end of theirenrollment period. Providers can revalidate their enrollment up to 90 days before their deadlines throughTexas Medicaid Healthcare Partnership (TMHP) Provider Enrollment on the Portal (PEP), available on theTMHP website.Providers can refer to the revalidation application type t/files/microsites/enrollment/index.html) on the Provider Enrollment on the Portal,A Step-by-Step Guide for instructions on revalidation. Providers who are unable to revalidateonline must download and
the Right. Care. update 2020 1. a the Right. Care. update 2020 . is waived for Telehealth/Telemedicine visits. Member cost-sharing (copay) is waived for COVID-19 testing. COVID-19 Telehealth and Telemedicine. The Policy below covers all lines of business. cont’d next page. back to TOC
May 02, 2018 · D. Program Evaluation ͟The organization has provided a description of the framework for how each program will be evaluated. The framework should include all the elements below: ͟The evaluation methods are cost-effective for the organization ͟Quantitative and qualitative data is being collected (at Basics tier, data collection must have begun)
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Dr. Sunita Bharatwal** Dr. Pawan Garga*** Abstract Customer satisfaction is derived from thè functionalities and values, a product or Service can provide. The current study aims to segregate thè dimensions of ordine Service quality and gather insights on its impact on web shopping. The trends of purchases have
Currently working to align with work on RightCare'sFrailty Pathway and the Geriatric Medicine workstream of NHS Improvement's Getting It Right First Time (GIRFT) programme . NHS RightCare is a programme of NHS England Piers Glen NHS RightCare Delivery Partner 8 bpollington@nhs.net 07710 152763. Title: PowerPoint Presentation
Chính Văn.- Còn đức Thế tôn thì tuệ giác cực kỳ trong sạch 8: hiện hành bất nhị 9, đạt đến vô tướng 10, đứng vào chỗ đứng của các đức Thế tôn 11, thể hiện tính bình đẳng của các Ngài, đến chỗ không còn chướng ngại 12, giáo pháp không thể khuynh đảo, tâm thức không bị cản trở, cái được
Since becoming an NHS England national programme in 2015 NHS RightCare has worked with systems on transformational change programmes, working on a large number of priority pathways, covering a wide range of conditions. By July 2017 the majority of NHS RightCare resources were devolved to regions,
