We strive to make information readily available to your office. We understand that your office is affected by any changes to the contracts that you hold through Mercy Managed Care. In efforts to keep you updated, this section is designed to update you on contract information including: new contracts, contract terminations, rate updates, TPA changes, and miscellaneous other news.

Please be aware that not all rate changes or contract updates below will necessarily pertain to everyone. We are also not able to publish specific rate information online as that data is confidential. Please see the additional resources below that are available to you to confirm specific contract participation.

• Mercy Network LLC providers: If you are participating with Mercy via a contract with Mercy Network LLC (this would include providers in Southwest Missouri,  Northwest Arkansas, Oklahoma and select providers in St. Louis), please reference your online matrix for specific contract participation.
• Mercy PHO providers: If you are contracted with Mercy via the Mercy PHO (this would include the majority of providers in the St. Louis region), please reference your PHO contract and enrollment packet for a listing of the contracts you hold through Mercy.
• Mercy employed/integrated providers in the St. Louis region: Please continue to reference the Managed Care hub on Baggot Street, and the Sharepoint site as your reference for contract participation.
• All other Mercy employed/integrated providers: Please continue to use the Managed Care hub on Baggot Street as your reference for contract participation.

Provider Changes
As a contracted provider, it is important to notify us immediately of changes to your practice such as: a new provider joining the practice, changes in billing information, provider leaving the practice, or adding a new clinic location.  Notification may help avoid claim denials.  Please submit changes by fax 417-820-3821 or email. Please include a W-9 Form if the change involves a new billing address or tax identification number.

Cigna – Zoll LifeVest Rental

Here are this week’s bulletin topics from the Kansas Medical Assistance Program (KMAP). Visit our provider news page to see Sunflower bulletins and other news.

KMAP BULLETIN: POS CODE FOR PROFESSIONAL SERVICES IN A FREE-STANDING PSYCHIATRIC FACILITY
Effective with processing dates on and after September 1, 2017, the place of service (POS) code 51 is to be used for professional services performed in a free-standing psychiatric facility (also known as an Institution of Mental Diseases or IMD). POS 21 is not appropriate since it states, “A facility, other than psychiatric.” Services provided with POS 51 will not be covered for beneficiaries between 22 and 64 years of age. Read more …

KMAP BULLETIN: PRIOR AUTHORIZATION REQUIRED FOR MEDICATIONS
Medications requiring prior authorization effective with dates of service on and after August 1, 2017. Read more …

Check out our Provider Training Resources!

Anthem Network Update August 2017

Cigna Network News July 2017

Update to Sunflower Bulletin SHPBN-2017-017

What is Changing

To reduce provider administrative burden and ease member access to services, Sunflower Health Plan is revising the requirement for participating (PAR) providers (providers contracted with Sunflower) to obtain a prior authorization for the specific codes listed below for physical, occupational and speech therapy. This activity does not change the benefits or benefit limitations of these services, only the need to authorize these services prior to treatment. Therapy codes not listed below require prior authorization.

Prior authorization is required after the 24th visit per discipline, per year, per member.The first 24 visits for a member’s PT, OT or ST do not require prior auth. Sunflower recommends providers inquire with members about their prior therapy visits for the year before initiating treatment without prior authorization.

Exceptions: Providers not contracted with Sunflower require prior authorization before providing a service/item to a member. Prior auth will still be required for any services rendered in the home setting, Home and Community Based Services (HCBS) and services related to the treatment of autism spectrum disorders, birth defects or developmental delays as outlined in state guidelines.

The state guidelines indicate that individuals may receive developmental therapy services to treat autism spectrum disorders (ASD), birth defects and other developmental delays in any appropriate community setting from any qualified provider with prior authorization and medical necessity documentation. Prior authorization applies to the following primary diagnosis codes.

• F84.0 – F84.9 Autism Spectrum Disorder
• F80.1 – F80.9 Developmental Speech and Language Disorder
• H93.25 Central Auditory processing Disorder
• F70 – F79 Intellectual Disabilities
• G80.0 – G80.9 Infantile Cerebral Palsy
• Q00 – Q89.9 Congenital Anomalies

These changes were effective on June 1, 2017.

Sunflower will continue to monitor utilization of services and make prior authorization adjustments as indicated, including reinstating prior authorization requirements for members or providers with patterns of not meeting medical necessity on post payment audits.

• 92507 TX SPEECH/LANG/VOICE/COMMUN/AUD DISORDER; INDIV
• 92508 TX SPEECH/LANG/VOICE/COMMUN/AUD DISORDER; 2/MORE
• 92526 TX  swallowing dysfunction and/or oral function for feeding
• 92613 FLX ENDO SWALLW CINE/VIDEO; PHYS I&R
• 92615 FLX ENDO LARYNG SENSY TST; PHYS I&R
• 92617 FLX ENDO SWALLW&LARYNG SENSY; MD I&R
• 97010 APPLIC MODAL 1/> AREAS; HOT/COLD PACKS
• 97012 APPLIC MODAL 1/> AREAS; TRACTION-MECH
• 97014 APPLIC MODAL 1/> AREAS; ELEC STIM
• 97016 APPLIC MODAL 1/> AREAS; VASOPNEUMATIC DEVICES
• 97018 APPLIC MODAL 1/> AREAS; PARAFFIN BATH
• 97022 APPLIC MODAL 1/> AREAS; WHIRLPOOL
• 97024 APPLIC MODAL 1/> AREAS; DIATHERMY
• 97026 APPLIC MODAL 1/> AREAS; INFRARED
• 97028 APPLIC MODAL 1/> AREAS; ULTRAVIOLET
• 97032 APPLIC MODAL 1/> AREAS; ELEC STIM EA 15 MIN
• 97033 APPLIC MODAL 1/> AREAS; IONTOPHORESIS EA 15 MIN
• 97034 APPLIC MODAL 1/> AREAS; CONTRAST BATHS EA 15 MIN
• 97035 APPLIC MODAL 1/> AREAS; ULTRASOUND EA 15 MIN
• 97036 APPLIC MODAL 1/> AREAS; HUBBARD TANK EA 15 MIN
• 97039 UNLIST MODAL (SPECIFY TYPE/TIME-CONSTANT ATTEND)
• 97110 THERAP PROC 1/> AREAS EA 15 MIN; EXERCISES
• 97112 THERAP PROC 1/> AREAS EA 15 MIN; BALANCE/COORDIN
• 97113 THERAP PROC 1/> AREAS EA 15 MIN; AQUATIC THERAP
• 97116 THERAP PROC 1/> AREAS EA 15 MIN; GAIT TRAINING
• 97124 THERAP PROC 1/> AREAS EA 15 MIN; MASSAGE
• 97139 THERAP PROC 1/> AREAS EA 15 MIN; UNLISTED
• 97140 MANUAL THERAP TECH-1/> REGIONS-EA 15 MIN
• 97150 THERAP PROC(S)-GROUP
• 97530 THERAP ACTIVITIES DIRECT PT CONTACT EA 15 MIN
• 97532 DEV CONGNITIVE SKILL-1:1-EA 15 MIN 0.68
• 97533 SENSRY INTEGRAT TECH-1:1-EA 15 MIN 0.74
• 97535 SELF CARE/HOME MGMT TRAIN-1 ON 1-EA 15 MIN
• 97537 COMMUNITY TRAIN-1 ON 1-EA 15 MIN
• 97545 WORK HARDENING/CONDITIONING; INIT 2 HR
• 97546 WORK HARDENING/CONDITIONING; EA ADD HR
• 97760 ORTHOTIC MGMT&TRAINJ UXTR LXTR&/TRNK EA 15 MIN
• 97761 PROSTC TRAINJ UPR&/LXTR EA 15 MIN
• 97762 CHECKOUT F/ORTHOTIC/PROSTC USE EST PT EA 15 MIN

For questions or concerns

The prior authorization code checker has been updated with these changes.

If you have questions about this bulletin or other provider resources, please contact Customer Service at 1-877-644-4623.

Follow the link below to the Summer edition of HealthChoice Network News.  Please remember that Mercy providers are only contracted with HealthChoice in the following areas:  Missouri – Joplin and Carthage  Kansas – Fort Scott and Columbus.

Healthchoice Provider Network News – Summer 2017

Here are this week’s bulletin topics from the Kansas Medical Assistance Program (KMAP). Visit our provider news page to see Sunflower bulletins and other news.

KMAP BULLETIN: MENTAL HEALTH MEDICATION EMERGENCY SUPPLY
Effective with processing dates on and after July 17, 2017, when mental health medications are needed without delay and prior authorization (PA) is not available, a 5-day emergency supply should be dispensed to the beneficiary until PA can be secured. Read more …

KMAP BULLETIN: HCBS REIMBURSEMENT
Effective with processing dates on and after July 15, 2017, and retroactive to dates of service on and after July 1, 2017, the fees for certain Home and Community Based Services (HCBS) Autism, Frail Elderly, Intellectual/Developmentally Disabled, Physical Disability, Severe Emotional Disturbance, Technology Assisted, and Traumatic Brain Injury codes increased by 3%. The codes are on the following page entitled HCBS Services. Read more …

Check out our Provider Training Resources!

Performance Analytics Platform

We are pleased to announce the launch of our Performance Analytics Platform, a new suite of modules designed to contribute to both the health of our members and the success of our providers.

The Performance Analytics Platform is comprised of two modules – Patient Analytics and Provider Analytics. Together, Patient and Provider Analytics will address both the clinical and financial components of the care that you deliver to our members, your patients.

The Performance Analytics Platform is a portal-based solution that is designed to provide you with timely and actionable clinical, cost and utilization data to improve care management of your patients as well as improve your performance against contracted incentives. Use of these tools will enable you to improve clinical outcomes for patients with the most critical care needs, while also achieving success in your contracted incentives. All providers should be aware that use of these tools falls within the bounds of the HIPAA Privacy Rule, and the provider manual has been updated to stipulate the limitations of the use of its content.

In 2016, our parent company, Centene, conducted pilots to test these tools with provider groups across seven of its health plans, including Sunflower Health Plan. This pilot provided valuable feedback, and we developed improvements and enhancements based on the participants’ responses.

Over the coming months, we will introduce training programs to support your use of these tools and ensure that you are able to get the most value from them.  So please keep an eye out for these materials.

About Patient Analytics

Patient Analytics is a population health-management tool designed to support you in the delivery of timely, efficient and evidence-based care to our members.

Patient Analytics includes:

• Population health management tools, including disease registries to support condition-specific member outreach
• Comprehensive reporting of care opportunities at member- and population-levels
• Claims-based patient histories from across the continuum of care (care team view)
• Exportable patient data to support chart records and reports

More information on Patient Analytics will be communicated at a later date.

About Provider Analytics

Provider Analytics is a cost and utilization tool designed to support our providers who participate in a value-based program.

Provider Analytics includes the following performance dashboards:

• Key Performance Indicators*- high-level summary statistics to help direct inquiries to plan specific opportunities
• Cost and Utilization – categorization and trending of costs and utilization of services by disease category and type of service
• Emergency Room – cost and trending of emergency room utilization and identification of potentially preventable visits
• Pharmacy – comparison and trending of generic vs brand cost and utilization
• Available now! Quality – identification and trending of quality performance and gaps in care
• Available now! Value-based Contracting: quarterly reports that include performance summaries and identifies number of members needed to meet care-gap targets and potential dollars to earn

*At this time Provider Analytics offers a high-level dashboard view of the above and member detail is not yet available for all dashboards, but will be available for quality-care gap reporting during the first release.

Provider Analytics prioritizes measures based on your performance to help identify where to focus clinical efforts in order to optimize your P4P payouts. This tool can be accessed through the provider portal on the right-hand side of the landing page. Clicking on Provider Analytics will take you to a landing page where you can select either the Quality tab to get care-gap information and/or the Value-based Contracting tab for scorecards. We encourage you to begin to explore this tool and incorporate into regular use to monitor your P4P progress.

Thank you again for your partnership with Sunflower Health Plan. We are committed to supporting you and our members through online tools and human support. Please don’t hesitate to reach out to our network specialists with any questions you may have.

Sunflower Secure Provider Portal

Here are this week’s bulletin topics from the Kansas Medical Assistance Program (KMAP). Visit our provider news page to see Sunflower bulletins and other news.

KMAP BULLETIN: UPDATED OUT OF STATE OUTLIER CCR
Effective with dates of service on and after July 1, 2017, the Out of State Outlier CCR is 0.5070. The DRG rate remains at $3471.00. Read more …

KMAP BULLETIN: KANCARE ALL MCO HCBS TRAINING
This will be an all managed care organization (MCO) collaborative session providing training for Home and Community Based Services (HCBS) providers. In addition to the training, each MCO will be available in breakout sessions all day. Read more …

Check out our Provider Training Resources!

New Mental Health Medication Prior Authorization Forms

To simplify the prior authorization (PA) process, KanCare has unified Managed Care Organization (MCO) and Fee-For-Service forms for medication prior authorizations. The same forms can be used with the three KanCare MCOs and the Fee-For-Service Program. All forms for drugs requiring prior approval for KanCare beneficiaries are located on the KDHE pharmacy webpage: http://www.kdheks.gov/hcf/pharmacy/default.htm.

Please see below for forms pertaining to the mental health medications.

Drug Specific Forms

• Forms designed to include drug specific prior authorization criteria.
  • Antipsychotic Dosing Limits
  • Antipsychotics for Children Ages 13 and Younger
  • Multiple Concurrent Antidepressants
  • Multiple Concurrent Antipsychotics
  • Multiple Concurrent Benzodiazepines
  • Multiple Concurrent Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
  • Multiple Concurrent Selective Serotonin Reuptake Inhibitors (SSRIs)
  • Stimulants and Other ADHD Agents In Children ages 3 and younger
  • Stimulants and Other ADHD Agents Dosing Limits
  • Stimulant Medications in Adults Ages 18 and older

Universal/General PA Forms

• Generic forms that can be used for any drug prior auth request. Please review drug criteria and complete form with relevant information.
  • Universal Clinical PA Form

Universal PDL PA Form