Opening in Summer 2019!Colonial Forge Medical Center

The newest Kaiser Permanente medical center in Stafford, Virginia – Colonial Forge Medical Center – will open in Summer 2019. Services at the new center include: Primary care, obstetrics and gynecology, radiology, laboratory, pharmacy, optometry, physical therapy, and mental health.

Colonial Forge Medical Center will be conveniently located on the campus of Stafford Hospital at 125 Hospital Center Blvd., Stafford, VA 22554 and contains more than 38,000 square feet of medical office space. Stay tuned for more information about our newest center!

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

JUNE 2019

ContentsPharmaceutical management information and updates 2

Medical coverage policy updates . . . . . . . . . . . . . . . . . 2

Medicare Advantage home health billing tips . . . . . . . 5

BD Alaris Large Volume Pump Module (Model 8100) recall . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Behavioral Health Utilization Management telephone number changes . . . . . . . . . . . . . . . . . . . . . . 7

UMOC fax numbers have changed . . . . . . . . . . . . . . . . 7

Keeping the Provider Directory up to date . . . . . . . . . 8

networknews

FOR PRACTITIONERS & PROVIDERS OF KAISER PERMANENTE

— 2 —

Medical coverage policy updatesThe following Kaiser Permanente Mid-Atlantic UM Criteria, Medical Coverage Policies (MCPs) and Transplant Patient Selection Criteria were approved between January 2019 to April 2019.

A. UM Standard Criteria1. 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.

2. 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.

3. 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.

4. Virginia Medicaid Community Mental Health Rehabilitative Services (CMHRS) Manual (for Virginia Premier’s Behavioral Health Services, for information only). • CMHRS, Chapter IV of the Department of

Medical Assistance Services (DMAS) Manual provide details on eligibility criteria & coverage requirements for behavioral health interventions that provide clinical treatment to individuals with significant mental illness or emotional disturbances.

CMHRS Covered Services a. Mental Health Case Management (H0023)b. Therapeutic Day Treatment (TDT) for Children/

Assessment (H0035 HA/H0032 U7)

— 3 —

c. Day Treatment/Partial Hospitalization for Adults/Assessment (H0035 HB/H0032 U7)

d. Crisis Intervention (H0036) e. Intensive Community Treatment/Assessment

(H0039/H0032 U9) f. Mental Health Skill-building Services (MHSS)/

Assessment (H0046/H0032 U8) g. Intensive In-Home/Assessment (H2012/H0031) h. Psychosocial Rehab (H2017/H0032 U6) i. Crisis Stabilization (H2019) j. Behavioral Therapy/Assessment (H2033/H0032

UA) k. Mental Health Peer Support Services or Family

Support Partners – Individual (H0025)* l. Mental Health Peer Support Services or Family

Support Partners – Group (H0024)* » Note: please refer to DMAS Manual for Peer

Services Supplement 5. MCG 23rd edition • Released on February 22, 2019 after systematic

evidence-base review by MCG. New clinical contents were added, and many guidelines have undergone content revisions in addition to the changes that are summarized in the MCG 23rd edition Summary of Changes document.

B. Patient Selection Criteria for Transplant

Approved by Kaiser Permanente Transplant Advisory Council on 01/24/2019

Approved by RUMC: 04/25/2019 1. Bone Marrow Transplant

2. Lung Transplant and Heart-Lung Transplant

3. Kidney Transplant

4. Simultaneous Pancreas Kidney (SPK) Transplant

5. Pancreas Transplant Alone (PTA) and Pancreas After Kidney (PAK) Transplant

6. Heart Transplant

7. Mechanical Circulatory Support Devices as a Bridge to Cardiac Transplant

Approved by RUMC: 02/20/20198. Liver Transplant

9. Intestinal Transplant and Intestine/Liver Transplant

C. Medical Coverage Policies• We 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. Cardiac RehabilitationEffective date: 01/29/2019• References were updated

2. Genetic TestingEffective date: 01/29/2019• References were updated

3. Virtual Colonoscopy: Maryland Jurisdiction onlyEffective date: 01/29/2019• Section IV. Clinical Indications for Referral

– considered CT colonography (CTC) to be medically necessary for certain conditions.

• Section V, C: Cautions and Exclusions – added MRI colonography as an exclusion; considered to be experimental/investigational; efficacy not yet established.

• References were updated4. Virtual Colonoscopy: DC, VA and Fed

Jurisdictions• Section IV. Clinical Indications for Referral

– considered CT colonography (CTC) to be medically necessary for certain conditions.

• Section V, C: Cautions and Exclusions – added MRI colonography as an exclusion; considered to be experimental/investigational; efficacy not yet established.

• References were updated5. Mastectomy External Prosthesis NEW Policy

Effective date: 01/29/20196. Autologous Stem Cell Cardiomyoplasty

Effective date: 02/20/2019• References were updated

— 4 —

7. Dental Services outside Medical Benefit• Effective date: 02/20/2019• References were updated

8. BiofeedbackEffective date: 02/20/2019• References were updated

9. Corneal Collagen CrosslinkingEffective date: 02/20/2019• References were updated

10. PanniculectomyEffective date: 03/27/2019• Section III, D: Coverage Criteria - addition of

surgery in areas where there is an inability to resolve an infection.

• References were updated11. Fetal Echocardiogram

Effective date: 03/27/2019• References were updated

12. Cranial Remodeling Band and HelmetsEffective date: 03/27/2019• References were updated

13. BlepharoplastyEffective date: 03/27/2019• References were updated

14. HomecareEffective date: 03/27/2019• References were updated

15. NICU Level of CareEffective date: 04/25/2019 » Section A, # 3 f – NICU Level Four

Requirements, added: High flow nasal cannula respiratory support (Vapotherm and all related humidified gas nasal cannula systems) with flows greater than 6L/minute, under LOC IV criteria -very intensive support services , which is a .modification from MCG NICU Care guideline and reflects a negotiation KP MAS had with Children National Medical Center of Washington DC at the end of 2018. It will an extremely small number of patient days but should be applied to all facilities.

• References were updated16. Transcranial Magnetic Stimulation for

Depression and Chronic MigraineEffective date: 04/25/2019• References were updated

17. Pectus Excavatum SurgeryEffective date: 04/25/2019• References were updated

18. Pre-Authorization Review, Single VisitEffective date: 04/25/2019• References were updated

19. Pre-Authorization Review, Multiple VisitEffective date: 04/25/2019• References were updated

Access to MCPs is only two clicks away in Health Connect.

Medical Coverage Policies can be accessed through the KP Clinical Library by using the web link at: clm.kp.org/wps/portal/cl/MAS/search_iframe?query=medical+coverage+policy&x=0&y=0.Click on the Clinical Library section on the right side of the KPHC Home page and then type in “medical coverage policy” in the search box. All medical coverage policies will be displayed.

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

— 5 —

Medicare Advantage home health billing tipsTo help ensure that your home health claims are paid accurately and timely, here are a few billing tips:

1. Medicare Advantage claims must be submitted to Kaiser Permanente as the primary payor.

2. Claims mailing address:

Mid-Atlantic Claims Administration Kaiser Permanente P.O. Box 371860 Denver, CO 80237-9998

3. In addition to the standard required fields, the following information is required for Medicare: Advantage member claims:

• Bill Types: 322, 327, 329, 32Q, 332, 337, 339, and 33Q

• Value Code 61 & Value $0.00 • Treatment Authorization Code (TAC) • HHA Admit Date (when applicable)

• Rev Code 0023 (All Inclusive Ancillary) and HIPPS Code

• NPI and Taxonomy 251E00000X• Value code 85 & county code (new for 2019)

4. In box 63 Treatment Authorization Code, indicate the Centers for Medicare & Medicaid Services’ (CMS) treatment authorization code, not Kaiser Permanente’s.

5. Corrected home health claims should be submitted to Kaiser Permanente after the final bill has been received and paid.

6. When submitting a replacement or corrected claim, include the original Kaiser Permanente claim number in box 64 Document Control Number.

For more billing information, visit CMS.gov to review the CMS HHA Manual and OASIS user manuals.

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 Premier 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 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.

— 6 —

BD Alaris Large Volume Pump Module (Model 8100) recallBD (formerly Carefusion), the manufacturer of the Alaris Infusion System, recently notified Kaiser Permanente that it expanded the recall on its Alaris Large Volume Pump Module (Model 8100). The recall involves the potential separation of bezel posts in the pump. Affected pumps could malfunction resulting in an over- or under-infusion of medication(s) and/or fluid(s). BD indicates that there were 12 reported safety events potentially related to this recall. For context, BD estimates its pumps are used to deliver approximately 161 million infusions worldwide. NO DEATHS were reported by BD. In addition, there have been NO reported safety events at Kaiser Permanente related to this recall.

BD is working with its customers on remediation and replacement plans for the affected pumps. See the attached recall notice for more information.

We, at Kaiser Permanente, want to bring this important patient safety matter to your attention. If your facility uses the Alaris Large Volume Pump, we strongly encourage you to engage BD, if you have not already done so, to learn the necessary steps to help mitigate the risk of an over- or under-infusion from occurring at your facility. Kaiser Permanente’s top priority is the safety of our members, patients, and communities.

As always, thank you for your continued partnership and vigilance in protecting the safety of our members during this critical period. Please don’t hesitate to contact Provider Experience with any questions or concerns. You may call Provider Experience at (877) 806-7470 or email us at provider.relations@kp.org. You may also go to our Community Provider Portal at providers.kp.org/mas to see this communication and the recall notice from BD.

— 7 —

UMOC fax numbers have changedIn an effort to streamline referral processes, there are new fax numbers for certain specialty services referrals and reauthorizations sent to the Utilization Management Operations Center (UMOC). All fax numbers, old and new, are currently in operation and will remain in operation. Note that some fax numbers did not change.

Please see the chart below for updated fax numbers.

We have updated our materials and provider manuals to reflect these changes. To access provider manuals, visit our Community Provider Portal at providers.kp.org/mas.

Referral Type Old fax number New fax numberDurable Medical Equipment (new URF referrals)

(855) 414-1695 (800) 660-2019

Durable Medical Equipment (reauthorizations - add codes to update existing referral)

(855) 414-1695 (855) 414-1695

All Physical Therapy/Occupational Therapy/Speech Therapy (PT/OT/ST) (new URF referrals)

(855) 414-1695 (800) 660-2019

Skilled Nursing Facility PT/OT/ST (reauthorizations)

(855) 414-1698 (855) 414-1698

Outpatient Rehab PT/OT/ST (reauthorizations) (855) 414-1698 (855) 414-1698

Home Health PT/OT/ST (reauthorizations) no existing fax number (855) 414-1695

Early intervention no existing fax number (855) 414-1695

— 8 —

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.

Behavioral Health Utilization Management telephone number changesThe Kaiser Permanente Behavioral Health Utilization Management unit has moved to our new administrative office building in New Carrollton. With that move, some telephone numbers have changed.

The new main telephone number for the Behavioral Health Utilization Management department is (301) 552-1212.

The new telephone number for Behavioral Health Utilization Management authorization nurses is (301) 552-1289 or (301) 552-1291.

Provider manuals have been updated to reflect these changes. You may access our provider manuals on our Community Provider Portal at providers.kp.org/mas.

— 9 — Version 12 (last updated 8/29/18)

**For 837 via CHCEven if your clearinghouse is not directly affiliated, they may re-route claims to one of our direct trading partners!

For more information, please contact:

Provider Self-Service Strategy Team:

(866) 285-0361, option 2or email: EDISupport@kp.org

Member ServicesContact Center:

For general claim inquiries, claim status, eligibility, obtain a copy of an EOP, or other member-related issues, please call the following numbers:

Region Phone NumberColorado 303-338-3600Georgia 404-261-2825Hawaii 877-875-3805

Northern CA 800-390-3510Southern CA 800-390-3510

Northwest 866-441-1221

EFT and ERAProviders seeking to register or manage account changes for EFT and ERA will need to use theCouncil for Affordable and Quality Healthcare(CAQH) Enrollment Tool, a secure electronic ERA/EFT registration platform.

This tool will eliminate the need for paper registration and reduce administrative time, costand allow you to register with multiple payers at one time.

Electronic Data InterchangeGet Connected! Submit Claims Electronically!

KAISER PERMANENTE • NATIONAL CLAIMS ADMINISTRATION

Electronic Data Interchange (EDI)The Benefits are Numerous!

• Electronic claims are not subject to postal delays.

• Claims may be transmitted 24 hours a day, seven days a week.

• Electronic claims are faster and more accurate than paper claims.

• Reduce phone calls by obtaining electronic claim status.

• An electronic remittance advice is offered to all electronic submitters. This provides a cost savings and allows the provider to post payments automatically.

To sign up, please contact your clearinghouse and provide the appropriate payer ID from the table below.

Clearinghouse Northern CA Southern CA Hawaii Georgia Northwest Colorado

ChangeHealthcare(CHC)

94135 94134 94123 21313 93079 91617

OptimumInsight/Ingenix N/A N/A N/A NG010** NG009** COKSRNavicure N/A N/A N/A 21313 N/A N/AOffice Ally 94135 94134 N/A N/A NW002 N/AAvaility (formerly REALMED)

N/A N/A N/A N/A N/A N/A

Relay Health RH009 94134 RH0011 RH008 RH002 RH003SSI NKAISERCA SKAISERCA N/A 21313 SS002 999990273

Regional Clearinghouse Payer IDs (835)

Mid-Atlantic 800-777-7902

Mid- Atlantic52095

NG008**N/A5209554294

RH010N/A

— 10 —

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.

Billing tips – corrected claimsWhen billing corrected claims or replacement claims, remember to include the original claim number on the claim form.• UB-04: In box 4 Type of Bill, enter the

frequency bill type code “7,” which indicates replacement of prior claim or corrected claim. Enter the original claim number in box 64 Document Control Number.

• CMS 1500: In field 22 Submission Code, enter “7,” which indicates replacement of prior claim. Enter the original claim number in the Original Ref. No. field.

— 11 —

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.

— 12 —

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

June 2019 The Mid-Atlantic Permanente Medical Group, P.C. 2101 E. Jefferson St., Rockville, MD 20852

Presorted

Standard

US Postage

PAID

Rockville, MD

Permit # 4297