2011 April/May - Physician and Practice Information
Please note that in order to qualify for the 50% bonus for Partners in Performance (PIP) 2011, the recognition from Blue Cross Blue Shield (BCBS) must be Physician Group Incentive Plan (PGIP) Patient Centered Medical Home (PCMH), not just PGIP.
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At times patients are included in your PIP measures, but have never been seen at your office.
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We no longer include medication refills in the e-Prescribing PIP measure. Also, Medicare members have
been removed from this measure. The basis for this measure is the total number of eligible filled prescriptions
between January 1, 2011, and December 31, 2011, presented to a pharmacy with “electronic” designated as
the Prescription Origin Code.
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These forms are available online.
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Unlike most other PIP measures, mammograms and cervical cancer screenings are not a yearly
requirement.
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Priority Health is committed to partnering with physicians to provide accountable care that optimizes
clinical outcomes and ensures the best experience while eliminating avoidable costs.
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This spring, we’re implementing an interactive voice recognition (IVR) system that will make your life
easier when you call our Provider Helpline.
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Here are some changes you may notice.
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Our newest commercial benefits plan was effective Jan. 1, 2011.
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Bronson and Allegiance Health recently received recognition.
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Effective May 1, 2011, we’ll update our standard pricing for injectable rates to Average Sale Price (ASP)
+10%. If no ASP is available, reimbursement will be set at AWP-15%. Immunization, vaccines and
toxoids pricing will remain at AWP-5%.
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Feeling confused and pressured? Have questions? Michigan Center for Effective IT Adoption (M-CEITA)
has answers.
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Priority Health has always been committed to protecting the confidentiality of our members’ personal
and medical information in all settings.
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According to a recent study, there is a discrepancy between a young adults' positive sexually transmitted infection (STI) status and their self-reported behavior of abstinence.
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The Alliance for Immunization in Michigan (AIM) tool kit is a great resource.
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In Michigan, vaccine recipients, their parents or legal representatives must be given the Michigan version
of the Vaccine Information Statement (VIS) because it includes information about MCIR, and state
law requires parents receive this notification.
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Effective April 1, 2011, non-sedating antihistamines (NSAs) and brand-name proton pump
inhibitors (PPIs) will be excluded from coverage for commercial and Medicaid members.
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Hypertension affects one in three adults and contributes to one in seven deaths. Barriers include poor adherence to prescribed medications, drug costs, side effects and insufficient physician-patient communication.
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View these online resources.
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Priority Health is working to remove high-risk medications from our Medicare formulary based on recommendations from the Agency for Healthcare Research and Quality and the Centers for Medicare and Medicaid Services 5-star quality initiative.
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Our formulary is updated up to six times a year, and Pharmaceutical Management Procedures are
reviewed annually.
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Priority Health timelines are in place for responding to urgent prior authorization (PA) requests.
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On January 18, and on March 15, 2011, the Pharmacy and Therapeutics (P&T) Committee met and
reviewed several drugs, policies and prior authorization criteria.
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Please ask your patients if they’ve had a glaucoma eye exam in the past one to two years. Medicare covers an annual glaucoma screening as a Medicare Part B benefit for high-risk patients.
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We’re calling our female members who’ve suffered a fracture within the past year and haven’t had a
bone density test or filled a related bone-strengthening prescription within six months of the fracture.
We want to encourage them to schedule a bone mineral density test.
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CMS recommends that patients diagnosed with COPD (ICD-9-CM Diagnosis 491, 492, and 496) get a
spirometry test at the time of their diagnosis or within six months of the diagnosis.
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Priority Health has again teamed up with CenseoHealth to conduct in-home health assessments on a select group of our Medicare Advantage members. These assessments are just one of the many initiatives we’re implementing to continue the exceptional service you and your patients — our members — expect from us.
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Priority Health Medicare Advantage plans offer coverage of both an annual physical with a PCP and a well
woman exam with an alternate PCP or specialist during each plan year.
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Details about HCPCS Codes G0438 and G0439.
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If you have questions about information in this edition of Physician and Practice Information, call your provider account representative, your provider account coordinator or the Provider Helpline at 800 942-4765.
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