Physician and Practice Information, March 2008

2007 Partners in Performance (PIP) Payments

We will combine PIP third-quarter and year-end settlement payments and distribute them in April 2008. If you have questions, contact your physician account executive (PAE) directly, or through the Provider Helpline at 616 942-4765 or 800 942-4765.

Patient Profile Update

Patient Profile will be updated for 2008 PIP searches within the next few weeks. Contact your PAE directly or through the Provider Helpline if you have questions.

Updated Benchmarks

Please note that the benchmark for HMO/POS and PPO Chlamydia is 49%, and the benchmark for both childhood and adolescent immunizations is 81%. These were stated incorrectly in previous communications. An updated PIP benchmark chart is below:

Measure	2008 Payout	2007 Payout	2008 Benchmark	2007 Benchmark
Disease Management
Diabetes - Controlled HbA1c	$100	$100	60% / 52% *	60%
Diabetes - Controlled LDL-C	$80	$80	51% / 44% *	53%
Diabetes - Monitoring for Nephropathy	$25	$25	87% / 86% *	85%
Diabetes - Annual Retinal Exam	$25	$25	71% / 68% *	69%
Diabetes - Blood Pressure Control	$100	$100	44% / 43% *	44%
Hypertension - Controlled Blood Pressure	$75	$90	68%	76%
Asthma	$100	$100	78% / 75% *	78%
Persistence of ACE/ARB Statin Therapy	$50	New Measure in 2008	36%	New Measure in 2008
Preventive Health
Childhood Immunizations	$175	$175	81%	87%
Adolescent Immunizations	$65	$65	81%	81%
Cervical Cancer Screenings	$10	$10	87%	88%
Mammography	$10	$10	77%	80%
Tobacco Status and Advice	$.15 pmpm	$.15 pmpm	90%	90%
BMI	$.15 pmpm	$.15 pmpm	90%	90%
Chlamydia Screenings	$15	$15	49% / 66% *	46%
Patient Satisfaction, Access & Availability
Open and Closed Status	$.25 pmpm	Measure Removed	Open 12 Months or 500 Mbrs	Measure Removed
Efficiency
Generic Prescriptions Filled	Shared Savings with Practice-Based Scoring and Settlement	Shared Savings with PFP Group-Based Scoring and Settlement	Shared Savings Begins at 70%	Benchmark
High-Tech Radiology Events per Thousand	Shared Savings with Practice-Based Scoring and Settlement	Shared Savings with PFP Group-Based Scoring and Settlement	Two methods - please refer to Technical Manual	Benchmark

* The first benchmark listed represents HMO/POS, ASO/PPO and Medicare Advantage plans. The second benchmark represents Medicaid plan members.

PIP 2008 - Preventive Health: Chlamydia Screening

The percentage of women 16-25 years of age who were identified as sexually active and had at least one test for Chlamydia during 2008.

Product Lines	HMO/POS, ASO/PPO, Medicaid
Ages	16-25 years of age as of Dec. 31, 2008
Continuous Enrollment	The measurement year with no more than one gap in enrollment of up to 45 days
Event/Diagnosis	Sex and age

PIP tip:
The Michigan Department of Community Health offers free mail-in urine Chlamydia lab kits. To learn more, or to order supplies, please contact your PAE directly or through the Provider Helpline at 616 942-4765 or 800 942-4765.

Requirements for EMR Incentive Program

Watch your e-mail for upcoming information on the 2008 requirements for the Electronic Medical Record (EMR) incentive program. We will provide a form for you to report on EMR implementation for 2007 Phase One participants. The form also will include an attestation section related to the 2008 Phase Two interoperability requirements. The completed forms will be due on March 31, 2008. Your PAE will e-mail more information and forms to you soon.

Immunization Notice

Immunizations may show as being complete in the Michigan Care Improvement Registry (MCIR); however, this does not guarantee the measure is met for PIP. MCIR sometimes allows "make-up time" to complete needed immunizations. PIP adheres to HEDIS® rules, which requires immunizations to be completed by the child’s 2nd or 13th birthday. Contact your PAE if you would like additional information.

Beaumont Hospitals and United Physicians Join Priority Health Network

Priority Health is proud to welcome Beaumont Hospitals and United Physicians to its provider network.

"As we expand across the state of Michigan, we are committed to providing our members with access to affordable, high-quality care," said Mike Koziara, vice president of the eastern region for Priority Health. "Partnering with Beaumont and United Physicians makes this possible."

The Beaumont agreement, which was effective Jan. 1, 2008, gives Priority Health members access to Beaumont facilities across southeastern Michigan. "Priority Health has a reputation of building strong partnerships with health care providers in local communities," said Mark Johnson, senior vice president of Beaumont Hospitals. "That’s why we're confident this agreement will benefit our patients as well as both of our organizations."

United Physicians will become a part of the Priority Health network effective March 1, 2008.

"We are excited about Priority Health and its commitment to southeastern Michigan," said Steven Grant, M.D., president and CEO of United Physicians. "Priority Health has been recognized as a leader among U.S. health plans. We are pleased to join the Priority Health network."

More information is available in our online news area.

Changing Requirements for Credentialing Site Visits

In November 2007, NCQA and the State of Michigan eliminated the requirement for health plans to conduct physician practice site visits as part of initial credentialing review and for new practice sites. Instead, the new requirement is for health plans to conduct practice site visits in response to specific member complaints. Site visits mandated for the following complaints will consist of on-site scoring and generation of an action plan to correct identified deficiencies. Member complaint categories necessitating reviews include:

• Physical accessibility
  
• Adequacy of space
• Cleanliness
  
• Confidentiality

NOTE: While we receive very few complaints from members about physical-site concerns, experience in conducting site visits demonstrates that some practices remain less diligent about "back-room" quality issues that directly relate to patient safety and are not visible to patients. These topics include, but are not limited to:

• Medication expiration logs
  
• Autoclave spore checks
  
• Refrigerator temperature logs

Priority Health will annually spot-check up to 50 randomly selected offices for the previously-low-scoring "back-room" quality processes.

NPI "Grace Period" is Coming to an End

Starting May 23, 2008, organizations and individuals are required to be identified by their National Provider Identifier (NPI). In fact, Medicare has communicated that all institutional claims not containing the proper NPIs will be rejected effective Jan. 1, 2008. This includes paper as well as electronic claims. For professional claims, Centers for Medicare and Medicaid Services (CMS) has stated that although not yet finalized, the rejection date will be prior to May 23, 2008.

The federal NPI regulations and communications are available starting at www.cms.hhs.gov/NationalProvIdentStand/.

Priority Health has been helping providers prepare for the NPI implementation using education, individual communications and warnings on EDI Service Receipts. To date, the service receipt warning has been for missing organization NPIs. This warning came as a surprise to many billers who, upon investigation, found that their NPI(s) were being dropped by their computer system or their clearinghouse.

The good news is that as a result of everyone’s efforts, 95% of electronic claims now contain organization NPIs. However, a significant number of these NPIs are incorrect. The most common mistake is that the individual NPI of the rendering/performing physician is sent as the NPI of the organization. As an aid, the EDI Team is adding new warnings to your EDI Service Receipt. Warnings will be given for the following conditions:

• Missing NPI
  
• Individual NPI submitted as the group/organization NPI
  
• When the entity identified by an NPI does not appear to match the entity identified in the National Plan and Provider Enumeration System (NPPES) NPI database (which is available monthly from CMS)

You can search and view the online version of the national NPI database at: https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do.

NOTE: No later than May 23, 2008, Priority Health and all other payers are required by federal regulation to reject all electronic claims that do not contain NPIs. Currently, all paper claims should be submitted using the new HCFA-1500 and UB04 forms, which have been redesigned to include NPIs (the old versions must no longer be used). Priority Health is requiring NPIs on all paper claims.

The NPI implementation for the health care industry has been a long and sometimes bumpy road. We are nearly there, and all parties will soon begin to realize the benefits. Thank you for your efforts and cooperation.

Code Added to Office Lab List

Effective Feb. 1, 2008, the following code was added to the office lab list.*

89322

Semen analysis; volume, count, motility and differential using strict morphologic criteria (e.g., Kruger)

A complete listing of office lab codes is available through the online provider manual at priorityhealth.com/provider/manual/billpymt/services/labs.

* Code may not apply to all physicians. See the “Office Lab Requirements” section in your contract for more information.

2008 CPT/HCPCS codes

The new 2008 vaccines listed below will not be covered, as they haven’t been approved by the FDA.

90650	Human Papillomavirus (HPV) vaccine, types 16 and 18, bivalent, three-dose schedule, for intramuscular use
90681	Rotavirus vaccine, human, attenuated, two-dose schedule, live for oral use
90661	Influenza virus vaccine, derived from cell cultures, subunit, preservative and antibiotic free, for intramuscular use
90662	Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use
90663	Influenza virus vaccine, pandemic formulation

We will continue to cover the approved vaccines as indicated in the online provider manual, located at priorityhealth.com/provider/manual/billpymt/services/vaccines.

Preferred Choice Claims

Preferred Choice members are not responsible for claims incurred prior to the Jan. 1, 2008, term date. Please note, we will be doing a runout of claims until July 31, 2008. Claims will be priced and sent to the Third-party Administrators (TPAs) that administer the claims.

Care Choices Medical Policy Changes

As former Care Choices members are being transitioned to Priority Health, it has become necessary to modify the Care Choices Medical Policies. These changes will be effective March 1, 2008. Below is a brief summary of the more major changes, which may impact your practice.

Code	Medical Service	Change
96116	Neuropsychological testing	Covered benefit, but now requires prior authorization
S8085 and G0235	Pet Scans	Specific codes are not a covered Benefit
0048T and 0049T	Artificial Heart, VAD	Specific codes are not a covered Benefit

Medicaid ID Number Update

Medicaid has changed from a 9-digit ID number to a 10-digit ID number. To accommodate these new numbers, Priority Health’s systems were upgraded in early March.

Until that time, here’s what to do:
For new Priority Health Medicaid member records:

• You’ll see a temporary 9-digit number (beginning in 947) for these members on paper remittance advices (RAs).
  
• DO NOT UPDATE YOUR RECORDS with this 947 number.
  
• DO NOT SUBMIT CLAIMS USING THIS TEMPORARY NUMBER. They will be rejected. Use the new 10-digit number.
  
• All electronic RAs will show the new 10-digit number assigned by Medicaid.
• ID cards and member-related letters will show the new 10-digit number.
  
• On March 10, 2008, all Priority Health communications, including paper RAs, will show the new 10-digit number.

For current Priority Health Medicaid member records:

• You will see the current 8-digit number on paper RAs from Priority Health until March 10, 2008. 
  
• You can update your records now and use the new 10-digit number, formed by adding two leading zeros to the current 8-digit number, on all claims you submit beginning Monday, Jan. 21, 2008.

How to Improve Colorectal Cancer Screenings

Colorectal cancer (CRC) is the second leading cause of cancer deaths in the United States and affects all racial and ethnic groups. African-Americans have the highest incidence of CRC of any group and are less likely to have undergone diagnostic testing and screening.

"Colorectal Cancer in African-Americans", American Journal of Gastroenterology, 2005.

What We Can Do to Help Prevent CRC

Physician’s Role	Priority Health Assistance
Recommend routine preventive CRC screening of men and women at age 50 (age 45 for those that are at high risk). Facts: African-Americans are more responsive to recommendations from their personal physician. If the physician fails to mention CRC screening, patients may conclude it is not necessary. 10.6% of African-Americans present with colorectal cancer before the age of 50. African-Americans have a higher prevalence of cancerous lesions in the proximal part of the large intestine.	Preventive Health Care Guidelines. If billed with a preventive diagnosis, we'll cover the cost of CRC preventive screenings and offer options: Fecal Occult Blood (FOB), sigmoidoscopy, barium enema and colonoscopy. Download a copy from the online Provider Center. Print copy available upon request.
Be aware of African-American men’s negative views towards CRC screenings; offer education and support, including personal risk factors. Facts: There is limited knowledge about CRC, and there are negative attitudes toward "manhood-depriving" procedures such as digital/instrumental rectal exams, which bring "shame or embarrassment." Cancer is viewed as a highly stigmatizing illness. Fear of finding cancer is a barrier.	Patient Education. Print "Stop Colon Cancer Before It Stops You" for your patients. Direct your patients to our website for additional information on risk factors, diagnostic tests and cancer treatment options
Use data to identify members who need a screening. Optimize your office strategies to include computer-based reminder systems.	Tracking Systems. Log in to "Patient Profile" at priorityhealth.com to find your patients age 50 and older who are due for a routine preventive CRC screening.
Assess your patients for tobacco use at every visit. Refer to Priority Health’s Tobacco Cessation and PIP programs. The smoking rate of African-Americans has increased and is a common risk factor for CRC.	Prior Authorizations. You can prescribe ANY smoking cessation therapy in our formulary for up to 12 weeks without prior authorization.

Additional Resources

• The Centers for Disease Control (www.cdc.gov) offers sample educational materials, screening strategies, research studies, statistics and more.
• The American Cancer Society at www.cancer.org.
• Screen for Life awareness campaigns offer materials and ideas to raise awareness of CRC screening and remove existing barriers. Go to www.cdc.gov/cancer/Screenforlife.

Physician Education
Visit www.medscape.com for free CME:

• Virtual Colonoscopy May Be Used First in Screening for Colorectal Cancer, valid through Oct. 10, 2008; 0.25 CME
  
• Immunochemistry Superior to Guaiac Test in Detecting Colorectal Cancer, valid through Oct. 9, 2008; 0.25 CME
  
• Obesity a Significant Risk Factor for Colorectal Cancer: Study (0 CME)