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Provider Digest | Issue 9

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Request your HEDIS Provider Performance Report today!

HEDIS Provider Performance Reports are now available. These reports reflect clinic-level care outcomes in 2021.

Your Provider Performance Report includes data that will help better prepare your clinic to assess and close patient care gaps in 2022 and 2023, including:

  • Number of eligible members by performance measure.
  • Number of members who received service.
  • The compliance rate for your site’s linked members.
  • The combined compliance rate for all Alliance providers.
  • NCQA 50th percentile, a nationally recognized minimum performance benchmark threshold.
  • NCQA 90th percentile, a nationally recognized high-performance benchmark threshold.

Nco tseg:  Reports are based on HEDIS requirements. Rates will differ from CBI reports.

To request your performance report, email the Alliance’s Quality Improvement Department at [email protected].

2022-2023 Synagis® (palivizumab) authorization guidelines

Respiratory syncytial virus (RSV) can cause a variety of respiratory illnesses in infants and young children. It most commonly causes a cold-like illness, but can also cause lower respiratory infections like bronchiolitis and pneumonia.

Synagis® (palivizumab) is a monoclonal antibody recommended by the American Academy of Pediatrics (AAP). It is recommended to be administered to high-risk infants and young children likely to benefit from immunoprophylaxis for RSV, based on gestational age and certain underlying conditions. Palivizumab 15mg/kg is administered intramuscularly once per month for a maximum of five doses in the peak RSV months. Palivizumab is not effective for the treatment of RSV disease.

AAP updated guidance

AAP has updated its guidance for using palivizumab prophylaxis to prevent hospitalization from severe RSV infection during the 2022-2023 RSV season.

With the shift in seasonality noted in 2021 and the current regional variability in interseason RSV cases, the AAP continues to support the use of palivizumab in eligible infants in regions experiencing rates of RSV activity similar to a typical fall-winter season. The AAP recommends initiating the standard administration of palivizumab, which consists of 5 consecutive monthly doses. This regimen provides serum levels associated with protection for 6 months, the length of a typical RSV season. The AAP will continue to monitor interseasonal trends and update guidance as needed if the RSV season extends longer than 6 months.

Read more about AAP’s updated guidance on their website.

The Alliance’s utilization criteria listed in Policy 403-1120 follows the current AAP recommendations. The Alliance will cover Synagis for members who meet the Conditions for Usage outlined in the policy.

 


DIAGNOSIS

Age 0-12 months at RSV season onset

☐ Infant born <29 weeks, 0 days gestation at birth.

☐ Preterm infant with chronic lung disease (CLD) of prematurity defined as gestational age <32 weeks, 0 days and a requirement for >21% oxygen for at least the first 28 days after birth.

☐ Infant with hemodynamically significant congenital heart disease (CHD) such as infants with acyanotic heart disease who are receiving medication to control congestive heart failure and will require cardiac surgical procedure and infants with moderate to severe pulmonary hypertension.

☐ Infant with cyanotic heart defects if deemed warranted by the infant’s pediatric cardiologist.

☐ Infant who undergoes cardiac transplantation during the RSV season.

☐ Infant with neuromuscular disease, significant respiratory disease or congenital anomaly that impairs the ability to clear secretions from the upper airway due to ineffective cough.

☐ Profoundly immunocompromised during the RSV season.

☐ Infant with cystic fibrosis and clinical evidence of chronic lung disease of prematurity and/or nutritional compromise.

Age 12 – <24 months at RSV season onset

☐ Preterm infant with chronic lung disease (CLD) of prematurity, who continued to require supplemental oxygen, chronic systemic corticosteroids or diuretic therapy during the 6-month period before the start of the second RSV season.

☐ Child who undergoes cardiac transplantation during the RSV season.

☐ Profoundly immunocompromised during the RSV season.

☐ Infant with cystic fibrosis and manifestations of severe lung disease or weight for length <10th percentile.

DOSING

☐ Was a NICU/hospital dose administered to the patient? Yes__________ No __________

☐ Expected date of first/next injection ______________________________

Synagis 15mg/kg IM every month in peak RSV months (Dose based on current weight): _______


Alliance authorization for Synagis billed as a medical claim

For providers who wish to bill the Alliance as a medical claim using a HCPCS code or “buy and bill,” please submit a prior authorization request via the Alliance Kws Kho Mob Lub Chaw Tswj Xyuas Tswvcuab Cov Ntaub Ntawv or by fax to 831-430-5851. A Synagis Statement of Medical Necessity Form is required to be submitted along with the prior authorization request.

Medi-Cal Rx authorization for Synagis billed as a pharmacy claim

As of January 1, 2022, prescriptions that are filled at a pharmacy are covered by Medi-Cal Rx instead of the Alliance. For more information on billing and prior authorization requests, please refer to the Medi-Cal Rx tus vas sab.

Thank you for caring for young, at-risk infants. If you have any questions about Synagis recommendations, please call Alliance Pharmacy Department at 831-430-5507.

How to submit Enhanced Care Management and Community Supports referrals

As of January 2022, Enhanced Care Management and Community Supports (ECM/CS) services are available to Alliance members. These services are part of the California Advancing and Innovating Medi-Cal (CalAIM) initiative to address social determinants of health and improve health equity statewide.

The Alliance is committed to supporting providers in utilizing ECM/CS services to help members receive quality care and achieve their best possible health outcomes. Below, please find information on how you can submit a referral and how referrals are processed by the Alliance.

How to submit an ECM/CS referral

Providers or requesting entities may submit ECM and Community Support referrals to the Alliance by:

Provider Portal referral

Registered providers can log in to the secured Alliance Provider Portal to submit, inquire about, cancel or add additional information to existing referrals.

Email, mail, or fax

Alliance providers can submit referrals for Enhanced Care Management or Community Supports by completing the following forms:

Please return completed forms to the Alliance’s Enhanced Care Management team by using one of the following methods:

  • Xa Email: [email protected].
  • Mail:
    1600 Green Hills Rd.
    Scotts Valley, CA 95066
    Attention: ECM Team
  • Fax: 831-430-5819.

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Refer a member to ECM/CS services by calling 831-430-5512.

Processing referrals and turnaround times

The Alliance processes submitted ECM/CS referrals within 5 business days, after which we will contact the referrer to let them know the outcome of the referral.

There are three possible outcomes:

  1. The referral is approved: Correspondence is sent to the servicing and requesting provider.
  2. The referral is denied: Correspondence is sent to the servicing and requesting provider, and a notice is sent to the member. This may happen if the member does not meet the criteria to be referred, or does not fit into one of the ECM/CS populations of focus (see tips below for more information).
  3. The referral is void: This only occurs if there is not enough information to process the referral. The Alliance ECM team will make attempts to obtain the missing information. Once the authorization has been pending for five business days with no additional information provided, it is voided. Correspondence is sent to the servicing and requesting provider.

Tips for a successful referral

  • Always include a population of focus when referring a member. Current eligible populations of focus include individuals and families experiencing homelessness, adult high utilizers and adults with serious mental illness (SMI) /substance use disorder (SUD). Check back on our website for updated information as we roll out additional populations of focus.
  • Referrals are a “no wrong door” approach. We accept all incoming referrals.

If you have questions, please call 831-430-5512.