December 2019

December 01, 2019

Featured Story: Welcome new AllWays Health Partners providers

As we reflect on the past year, we are thrilled to share the successes we've experienced in expanding our provider network throughout Massachusetts, New Hampshire and Rhode Island. Since the beginning of the year, we've added almost 6000 providers to our network.

In This Issue

Welcome new AllWays Health Partners providers
New in 2020: no copays for the first three pediatric sick visits
Reminder: use the provider portal for member eligibility and claims status
Simplifying the authorization process
Medical policy
Formulary updates
Available provider resources
Contact information

To support our growing provider network, we're looking at adding new resources and reviewing our processes to make it even easier for you to do business with us. Don't forget to sign up to receive all our communications, such as the Best Practice blog and Clinical Digest newsletter, to stay connected.

New in 2020: no copays for the first three pediatric sick visits

As a reminder, many AllWays Health Partners plans will include $0 cost sharing for the first three pediatric sick visits with an in-network PCP and $0 cost sharing for the first three pediatric visits with an in-network behavioral health provider. Check out our Best Practice Provider Blog for more information.

Reminder: use the provider portal for member eligibility and claims status

The provider portal gives you instant and real-time access to validate member eligibility and check on claims status. Beginning January 1, we will direct all phone calls to verify member eligibility or check on claims status to the provider portal. This will give you a faster response time for urgent inquiries that requires support from provider service staff.

Please share this important information with your staff and with third-party billers who call us on your behalf.

Registering for the provider portal

Getting setup with the provider portal is easy. We've set up this useful webpage with important tips and resources to help you get started.

For registration support, contact prweb@allwayshealth.org.

Simplifying the authorization process

Maternity

To reduce the administrative burden on providers, we no longer require authorization on maternity claims for all lines of business. Please refer to the authorization guidelines for more detailed information.

MassHealth still requires hospitals to submit a notification of birth for all newborns born to MassHealth eligible women. Please complete the form and fax it to 617-887-8777. To ensure timely enrollment of newborns and payment of related claims, please also email a copy of the notification of birth to enrollment@allwayshealth.org.

Additional services that no longer require prior authorization

Insulin Pumps (effective 10/21/19 for all lines of business)
Hospice (effective 12/1/19 for all lines of business)
Wound Vac (effective 12/1/19 for commercial line of business only)

Authorization and referral information

Medical policy

The following medical policy updates are effective December 1, 2019:

Insulin Pumps - Annual update. Prior authorization requirement removed, as reflected on table 1 on page 1. Removed exclusion referencing pulsatile intravenous insulin therapy. Definitions and references updated.
Artificial Pancreas Device System - Annual review. References updated.
Continuous Glucose Monitors - Annual review. References updated.
Vitamin D Screening and Testing in Adults - Annual review. References updated.
Zolgensma - New medical policy. Zolgensma is an adeno-associated virus vector-based gene therapy indicated for the treatment of pediatric patients less than 2 years of age with spinal muscular atrophy (SMA) with bi-allelic mutations in the survival motor neuron 1 (SMN1) gene.

VIew all medical policies.

Formulary updates

AllWays Health Partners regularly reviews and updates our formulary to ensure alignment with the industry. Check out the latest updates effective February 1, 2020.

For the latest information on our pharmacy programs, visit our online formulary today.

Available provider resources

Our website (provider.allwayshealthpartners.org) provides you with important resources and information to support you and your staff. Here's a sample of what resources are available:

Clinical Resources:

Medical Policies - Medical policies provide you with the coverage criteria for specified conditions. You can find more information on the utilization management (UM) decision making process and how to obtain UM criteria in the Provider Manual.
Clinical Contact Information - Clinical staff is available at 855-444-4647 Monday-Friday (8:30 AM - 5:00 PM). After hour coverage is available after 5 PM on weekdays and on the weekends.
Case Management Programs - You can get more information on specific programs and how you can refer a member into one of our case management programs. Providers can refer by emailing caremanagement@allwayshealth.org
Tobacco Cessation - For members who are trying to quit tobacco, we offer a tobacco cessation program run by our Certified Tobacco Treatment Specialists. Providers can refer by email: quitsmoking@allwayshealth.org
Health Coaching - Health coaching is available for members trying to improve eating habits, increase their physical activity, manage weight and decrease stress. Our health coaches have all completed the rigorous Wellcoaches® school of coaching training program. Providers can refer by emailing: healthandwellness@allwayshealth.org

Provider Manual

The Provider Manual includes important information on how you can support your patient. Topics in the Provider Manual include:

Quality Improvement Program
Utilization Management Decision-Making - This includes information regarding our decision-making process and procedures. We do not specifically reward practitioners or other individuals conducting utilization review for issuing denials of coverage or service, nor do we provide financial incentives to UM decision-makers to encourage decisions that result in under-utilization.
Credentialing and Recredentialing Processes
Member Rights & Responsibilities
Practitioner Rights & Responsibilities
Interpreter Services

Pharmacy Benefit Program

Our website gives you the most up-to-date information about our Pharmacy programs, covered medications and the current medical necessity criteria. Pharmacy programs include:

Excluded Medication - A medication which is considered to be excluded from the pharmacy benefit.
Pharmacy & Therapeutics Committee - This Committee is chaired by the Medical Director responsible for pharmacy and is composed of practicing pharmacists and practicing providers with varying specialties, including behavioral health, internal medicine and pediatrics. It meets regularly throughout the year, no less frequently than quarterly.
Prior Authorization - A pharmacy program which limits access to a medication by establishing criteria for appropriate use of a medication. These criteria must be met and documentation sent to us before the medication will be covered. Prior authorization is also required for exception to our mandatory generic medication pharmacy benefit.
Quantity Limit - A pharmacy program that limits the number of units per time period for a specific medication based on recommended doses.
Step Therapy - A pharmacy program which allows patients who meet criteria to have coverage for their prescription adjudicate without review based on available medication history.
Mandatory Generic - A pharmacy program which requires a trial of an FDA approved generic substitution for a brand name medication, if it is available.
Tier Placement - A pharmacy program that places medications in one of six co-payment tiers for benefit plans with a six-tier pharmacy benefit.
Therapeutic Interchange/Substitution - A pharmacy program that involves the dispensing of a chemically different drug, considered therapeutically equivalent, i.e., will achieve the same outcome, in place of a drug originally prescribed by a physician. The drugs are not generically equivalent. Therapeutic substitutions are done in accordance with procedures and protocols set up and approved by physicians in advance. Therefore, the pharmacist would not have to seek the prescribing physician's approval for each interchange.

Visit our webpage.