Medicaid Member Messaging ProgramOn May 24th, Kaiser Permanente’s Mid-Atlantic Medicaid Department deployed an SMS text message program targeting Maryland and Virginia Medicaid members. This program reaches beyond the text message appointment reminder functionality already in use throughout the Kaiser Permanente organization and will engage with our Medicaid population in a more direct, conversational manner around specific programs and healthy behaviors.

Studies have revealed increased member engagement when utilizing text messaging and other alternative methods of communication. With this in mind, in partnership with the Mid-Atlantic Permanente Medical Group and our vendor, Health Crowd, the Medicaid Department has developed an initiative with three overarching goals: 1) engage and establish trust with this hard-to-reach population through an alternative method of contact; 2) encourage early adoption of the Kaiser Permanente health model; and 3) stress the importance of regular and routine health care. Using Medicaid member information, we will target four populations with this new technology.

Produced by Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.,

with the Mid-Atlantic Permanente Medical Group, P.C.

Web site: Providers.KaiserPermanente.org/mas

JULY 2018

ContentsProvider access to health education materials . . . . . . .2

Medical coverage policy update . . . . . . . . . . . . . . . . . . .3

Pharmaceutical management information and updates . . . . . . . . . . . . . . . . . . . . . . . . .6

2017 Provider and practitioner experience survey results . . . . . . . . . . . . . . . . . . . . . . . . .7

All Maryland Medicaid Providers MUST Enroll in ePrep . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

Notification of Change . . . . . . . . . . . . . . . . . . . . . . . . . .10

Keeping the Provider Directory up to date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

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FOR PRACTITIONERS & PROVIDERS OF KAISER PERMANENTE

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The four SMS texting campaigns include:• New member welcome messages: greets

newly enrolled Medicaid members and provides contact information for Kaiser’s Appointment Line so that they can make their first appointment. Eligible members include males and females, ages zero to 64;

• Maternal care messages: connects with pregnant Medicaid members to keep them informed about their prenatal healthcare and the wellbeing of their anticipated newborn. Eligible members include females, aged 18 and older;

• Reminders for redetermination: prompts Medicaid members to update their financial information with the Department of Health as required on an annual basis. Eligible members include males and females, ages zero to 64; and

• Members never seen by a Kaiser Permanente physician: targets individuals that have not yet come to Kaiser Permanente for an initial visit will be reminded that they can easily make an appointment with us. Eligible members include males and females, ages zero to 64.

The Medicaid Department will be tracking metrics to measure the efficacy of this new communication tool. With this program, we are hoping to achieve better health outcomes for our Medicaid population and improve the overall health of the Kaiser Permanente membership. If you have any questions please contact the Medicaid Department.

Provider access to health education materials Kaiser Permanente physicians and network providers have access to all health education materials to provide to patients as part of the After Visit Summary or to supplement discussion from patient visit.

Content can be viewed through the centralized internal “clinical library” which is an electronic inventory of health education information that can be used for all visit types. Health education content is also embedded into KP HealthConnect for inclusion in member After Visit Summary or sent via secure messaging. For health education programs, providers can:

• Refer or direct book members into health education programs through eConsult system

• Provide members with information on how to self-register through KP HealthConnect After Visit Summary or hard copy flyers

Additional information on health education programs, tools, and resources is available by:• Visiting kp.org/healthyliving• Contacting the Health Education automated line

(301) 816-6565 or 1-800-444-6696 (toll free).

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Medical coverage policy update March - April 2018The following Kaiser Permanente Mid-Atlantic States Utilization Management Criteria, Medical Coverage Policies (MCPs) and Transplant Patient Selection Criteria were approved by the Regional Utilization Management Committee (RUMC) between March 2018 to April 2018.

A. New or Updated Medical Coverage PoliciesWe develop MCPs in collaboration with specialty service chiefs and clinical subject matter experts. MCPs specify clinical criteria supported by current peer reviewed literature and are used to guide decisions related to request for health care services such as devices, drugs, and procedures. The policies are reviewed and updated annually, reviewed for approval by the Regional Utilization Management Committee (RUMC), and are periodically reviewed by regulatory and accrediting agencies. Except where noted, our MCPs are primarily applicable only to commercial members.

1. Autologous stem cell cardiomyoplasty• Revision date: 03/29/18• References were updated

2. Biofeedback• Revision date: 03/29/18• Section II, C: Biofeedback Indication – edited

as third line treatment for neuro/muscular related conditions

• References were updated

3. Corneal cross-linking• Revision date: 03/29/18• References were updated

4. Dental services – covered outside of medical benefit• Revision date: 03/29/18• References were updated

5. Blepharoplasty• Revision date: 04/30/18• References were updated

6. Fetal echocardiogram• Revision date: 04/27/18• References were updated

7. Cranial remodeling bands and helmet• Revision date: Revision date: 04/27/18• References were updated

8. Home Care• Revision date: Revision date: 04/27/18• References were updated

9. Panniculectomy• Revision date: 04/27/18• Section III, A: Coverage Criteria: Pannus

description replaced with a grading scale.• Section VI. Added the panniculus grading

system • References were updated

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10. Pectus excavatum surgery• Revision date: 04/27/18• Section IV. Indications for referral - edit made

on letter C: Surgical repair of chest deformity of Poland’s syndrome when functional deficits are caused by the deformity, demonstrated by cardiopulmonary compromise.

• References were updated

11. Transcranial magnetic stimulation• Revision date: 04/30/18• Section IV, B: Referral Process and Indications

for TMS to treat chronic migraine pain: deleted # 3, home and medical center based therapy & replaced with indications for acute and prophylactic treatment of migraines for patients between age of 18 and 65.

• Section V, C: TMS Contraindications: added shunts, stents, electrodes, shunt valves.

• References were updated

12. NICU Care (LOC II_IV) admission and discharge• Revision date: 04/27/18• References were updated

13. Medical necessity for pre-authorization, single visit• Revision date: 04/27/18

14. Medical necessity for pre-authorization, multiple visit• Revision date: 04/27/18

Access to MCPs is only two clicks away in Health Connect. Medical Coverage Policies can be accessed through the KP Clinical Library at https://clm.kp.org/wps/portal/cl/MAS/search_iframe?query=medical+coverage+policy&x=0&y=0.

Click the Clinical Library section on the right side of the KPHC Home page and then type “medical coverage policy” in the search box. All medical coverage policies will be displayed.

B. National Transplant Service (NTS) patient selection criteria1. Bone Marrow Transplant2. Intestinal Transplant and Intestinal/Liver

Transplant3. Liver Transplant

C. Utilization Management Standard Criteria

1. MCG are evidence-based clinical guidelines that provide best practices criteria and content for healthcare professionals across patient’s continuum of care, to support decisions and to ease patient transition between healthcare settings. The six MCG Care Guidelines that are being used by Kaiser Permanente Mid-Atlantic States include: Inpatient and Surgical Care, General Recovery Guidelines (GRGs), Ambulatory Care, Recovery Facility Care, Behavioral Health and Home Care. The MCG clinical guideline has transitioned from 21st edition to 22nd edition on April 23, 2018.

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2. American Society of Addiction Medicine (ASAM) criteria (for information only) The American Society of Addiction Medicine (ASAM) criteria is being used for all Virginia Medicaid Chemical Dependency level of care decisions and referral determinations, as required by the Virginia Department of Medical Assistance Services (DMAS) effective April 1, 2017. MCG criteria is not to be used for this service category in this group of population.

3. Utilization Management Criteria for Durable Medical Equipment (DME), orthotics, and prosthetics (for information only)• UM will continue to use Centers for Medicare

and Medicaid Services (CMS): National and Local Coverage Determinations as the primary criteria for our Medicare Cost and Medicare Advantage members; and,

• UM will continue to use CMS National and Local Coverage Determinations for DME, orthotic, and prosthetic devices and services only in the absence of MCG or medical coverage policy for Commercial and Medicaid members in Maryland and Virginia.

4. The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) (for information only) • Will continue to be in use for Medicaid

members in Maryland and Virginia as required by the federal government. The federal mandated services include screening, vision, dental, hearing, and diagnostic services in

addition to treatment health care services for all physical and mental illnesses or conditions discovered by any screening and diagnostic procedures. The federal requirements for children under age 21 who are enrolled in Medicaid may be found at Medicaid.gov, search EPSDT.

Please contact the Utilization Management Operations Center (UMOC) at (800) 810-4766 to receive a copy of the UM guideline or criteria related to a referral.

All Practitioners have the opportunity to discuss any non-behavioral health and or/behavioral health Utilization Management (UM) medical necessity denial (adverse) decisions with a Kaiser Permanente Physician reviewer (UM Physicians).

If you have clinical questions on use of our criteria, please feel free to contact:

Claudia Donovan M.D. Physician Referral Reviewer Claudia.K.Donovan@kp.org

If you have administrative questions concerning accessing or using our criteria, please contact:

Marisa R Dionisio, RN Marisa.R.Dionisio@kp.org (301) 816-6689

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Pharmaceutical management information and updatesThe KPMAS Regional Pharmacy & Therapeutics (P&T) Committee approves drug formularies for all lines of business, Commercial, Marketplace/Exchange, Medicare, Virginia Medicaid and MD HealthChoice (Medicaid).

The Regional P&T Committee, with expert guidance from various medical specialties, evaluates, appraises, and selects from available medications those considered to be the most appropriate for patient care and general use within the region. The purpose of the formulary is to promote rational, safe, and cost-effective drug use.

The formularies are updated monthly with additions and/or deletions approved by the Regional P&T

Committee. The most recent information on drug formulary updates or changes can be accessed via the online Community Provider Portal for affiliated practitioners available at http://providers.kaiserpermanente.org/html/cpp_mas/formulary.html. To view the P&T Memos, you will be redirected to the KPMAS Clinical Library, a secured network, and asked to sign in and/or register for access.

A printed copy of each drug formulary is available upon request from the Provider Relations department, which can be contacted via email at Provider.Relations@KP.org

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2017 Provider and practitioner experience survey resultsThank you to all who participated in the 2017 survey which reflects your opinion about the Utilization Management (UM) functions that support continuing care, the discharge process, and outpatient referral management. You may recall that we reached out to you several times last year to encourage your participation in this survey poll.

Key Findings for Transition Process: Overall Satisfaction of Referring Physicians (Primary Care Physicians and Specialists)• For primary care physicians, the overall

satisfaction with transition to all care facilities did not significantly change year to year.

• For primary care physicians, overall satisfaction was highest for the transition process from Hospice and lowest for DME Post Discharge.

• Specialists overall satisfaction with the transitions for Hospital, Behavioral Health, and ECM Support Staff all significantly increased from 2016 to 2017

• Specialists rated the Hospice transition highest and reported the lowest satisfaction with Skilled Nursing Facilities and DME Post Discharge.

In 2017, we continued to focus on all objectives associated with the Implementation of the “Care Without Delay” model to impact overall

utilization. This model represents a paradigm shift in the manner that we conduct business in our premier core hospitals and our transitional care. Care without Delay is the integration of care transformation with patient flow infrastructure to ensure that the right care is delivered at the right time and in the right venue. It aligns delivery system processes to improve care timeliness, remove system barriers to care and provide for a great care experience.

We are proud to share some of our accomplishments for 2017: • Extended coverage of our Patient Care

Coordinators to 10-hour shifts to continue enhancement of our discharge planning processes

• Employed the use of an Escalation Process Policy in real time to remove barriers that may prevent a timely discharge

• Achieved a consistent average discharge volume each of the 7 days per week and decreased avoidable delays in discharge on weekends through the presence of onsite managerial oversight on weekends, in addition to weekdays.

• Developed and implemented tools to enhance our ability to measure hospital days to support discharge planning efforts.

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• Leveraged data to identify high risk members for Case Management engagement

• Collaborated with the Emergency Care Management Patient Transition Team to improve, heighten and intensify focus on prepatriation and repatriation efforts throughout all service areas

• Behavioral Health enhanced collaboration effort between the IP and OP BH teams to coordinate efforts to prevent readmission for patients who were readmitted within the past 30 days

Key Findings for Outpatient Referral Management at the Utilization Management Operations Center (Primary Care Physicians and Specialists)• Satisfaction results for the Utilization

Management Operations Center (UMOC) units are similar to satisfaction with the transition process.

• PCPs had the highest satisfaction with PT/OT/Speech Referral Staff and lowest satisfaction with DME Referral Staff among all UMOC units.

• Specialists were most satisfied with PT/OT/Speech Referral Staff and least satisfied with DME Referral Staff.

• DME hotline showed improved satisfaction with both PCPs and Specialists.

For outpatient referral management at UMOC we implemented the following to improve referral processing: • Initiated a UMOC Optimization Project to

examine and improve overall efficiencies in the referral management process.

• Successful implementation of extended operational UMOC staffing 7 days per week, including holidays.

• Streamlined the ordering of the top four DME items: CPAP, Hospital Bed, Diabetic Shoes and Patient Lift through the creation of a standardized referral entry order process. Within three months of implementation, reduction in follow up information requests and shortened approval turn-around time were noted.

• Established the use of a standard ordering process for ease in requesting the following DME items: oxygen, manual wheelchair and ostomy supplies. Additional items are currently in process to include compression garments, enteral feeds, wound supplies and negative pressure wound therapy also known as wound vac) and services such as home health are scheduled for release later this year

• We continue to enhance the roles of the DME Benefit Coordinators acting as resource and support for physicians, members and health plan members throughout the region to research and resolve any service delays, problem solve customer complaints.

• Improved partnership with our contracted vendors continues to simplify work flow on DME referrals in response to the constantly changing and complex Medicare rules.

Throughout 2018 and continuing in 2019, we will identify, streamline and address UM processes to improve our transitions in care along with the referral management procedures.

If you already completed our 2018 survey, we appreciate your participation. If you have not done so, we value your opinion about the Utilization Management functions that support continuing care, discharge processes, and outpatient referral management. The 2018 Practitioner Survey is currently active and will be available to you through 7/31/2018. It can be accessed at https://kp.co1.qualtrics.com/jfe/form/SV_0U6pBazuPZ18n5z or by scanning this QR barcode:

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All Maryland Medicaid Providers MUST Enroll in ePrepNew Federal rules require that MCO providers enroll with the MCO’s state Medicaid agency (42 CFR Part 438, Subpart H). To continue to render Medicaid reimbursable services, you must enroll with the Maryland Medical Assistance Program (Medicaid), even if your practice will be providing services only to HealthChoice participants. Enrolling with Medicaid does not mean that you must provide services to Fee-for-Service (FFS) participants.

The Maryland Department of Health (MDH) has deployed its new provider enrollment system, called ePrep (electronic Provider revalidation and enrollment portal). The ePrep portal will replace paper applications for a more efficient and streamlined process to enroll rendering providers and facilities that provide care to the Maryland Medicaid population. MDH is asking all currently enrolled rendering providers to reenroll through ePrep. All providers are expected to reenroll or

risk being ineligible for reimbursement. Please visit eprep.health.maryland.gov to submit your enrollment application or create an account linked to your existing enrollment.

Please complete your enrollment as soon as possible and contact the Provider Experience team if you have any questions about this new requirement.

If you have any enrollment questions, please contact (844) 4MD-PROV [(844) 463-7768]. For more information about Medicaid’s ePREP, and to access training information please go to health.maryland.gov/ePREP.

The Maryland Department of Health previously sent notices to your office regarding ePrep. Please visit their website at health.maryland.gov for additional information.

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Keeping the Provider Directory up to datePlease use the sample letter format on the next page to update us with any changes you may have through out the year. It is very important that we have the most accurate information when we pull our data for the directory.

Changes may be made by fax to: (855) 414-2623, email Provider.Relations@kp.org, or by mail:

Kaiser Permanente Provider Experience 2101 East Jefferson St., 2 East Rockville, MD 20852

If you would like to request a provider directory please contact Member Services:

• For within the Washington, D.C., metro area call (301) 468-6000, (301) 879-6380 TTY

• All other areas outside of Washington, D.C., metro area call (877) 777-7902, (800) 700-4901 TTY.

Notification of ChangeIV Piggyback delivery system for antimicrobial therapies and lab reports from Non-Kaiser laboratories

Effective July 2, 2018, Kaiser Permanente Home Infusion Pharmacy will be dispensing antimicrobial therapies in piggyback mini-bags and IV tubing sets with rate controls. Elastomeric pumps and CADD pumps will continue to be available but will be utilized for circumstances requiring use of such devices.This change aligns our home infusion pharmacy and nursing practices with the current industry standards.

When a non-Kaiser Permanente laboratory is utilized for home infusion patient lab samples, please fax the results of the laboratory test to the Provider, as well as the Kaiser Permanente Home Infusion Pharmacy.

The Fax number for the Kaiser Permanente Home Infusion Pharmacy is (703) 249-7923.

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Company Logo or Letterhead

<<Date>>

Requestor: Requestor’s Correspondence Address:Requestor’s Phone #:Email:Tax ID#:Effective date of change(s):

Reason for the request:

Address change (Specify if practice location or billing address is changing)• Specify if adding or deleting address• Include old and new demographic information when sending request • (Street Address, City, State, Zip, Phone, Fax and NPI)• Billing/Payment Address• Management Correspondence Address (include Phone & Fax Number)

Adding a provider to an existing group or deleting a provider from an existing group• Specify if adding or deleting provider• Include the below listed information if adding or deleting a provider:

* First Name, Middle initial, and Last Name* Gender* Title (MD, CRP, CRNP, PA etc.)* Date of Birth* NPI #* CAQH #* UPIN or SSN* Medicare #* Medicaid Participation State(s)* Medicaid #* Practicing Specialty * Practicing Service Location only (include Phone & Fax Number)* Billing/Payment Address (include W-9)* Management Correspondence Address (include Phone & Fax Number)* Hospital Privileges * Foreign Language

**A copy of provider licenses in all practicing states is required**

Changing the Tax Identification Number and/or the name of an existing group • Include old and new Tax ID Number and/or group name• Include effective date of the new Tax ID Number and/or group name• Include a signed and dated copy of the new W-9• Billing/Payment Address• Management Correspondence Address (include Phone & Fax Number)

** Email the request to the Provider Experience Department at Provider.Relations@kp.org or fax to (855) 414-2623.

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The Mid-Atlantic Permanente Medical Group, P.C. 2101 E. Jefferson Street Rockville, MD 20852

July 2018 The Mid-Atlantic Permanente Medical Group, P.C. 2101 E. Jefferson St., Rockville, MD 20852

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Rockville, MD

Permit # 4297

Utilization management affirmative statement Kaiser Permanente practitioners and health care professionals make decisions about which care and services are provided based on the member’s clinical needs, the appropriateness of care and service, and existence of health plan coverage. Kaiser Permanente does not make decisions regarding hiring, promoting, or terminating its practitioners or other individuals based upon the likelihood or perceived likelihood that the individual will support or tend to support the denial of benefits. The

health plan does not specifically reward, hire, promote, or terminate practitioners or other individuals for issuing denials of coverage or benefits or care. No financial incentives exist that encourage decisions that specifically result in denials or create barriers to care and services or result in underutilization. In order to maintain and improve the health of our members, all practitioners and health professionals should be especially diligent in identifying any potential underutilization of care or service.