September 2024 Provider News
Date: 09/30/24
In this issue:
- General Updates - Availity Essentials – Coming Soon
- Quality - Adult ASAM Criteria 4th Edition has been released, Breast Cancer Screening, Wellcare Quality
- Pharmacy Updates - Wegovy Coverage Reminder, Appropriate Use of GLP-1 Agonists, Evolent Update-Medical Oncology
- Payment & Clinical Policy - Monthly Updates
- Apple Health Core Connections - 2023 Highlights
- Training/Education - Upcoming October Trainings
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General Updates
Availity Essentials – Coming Soon
As a commitment to making it easier to work with us, Coordinated Care has chosen Availity as its partner for both a new, secure provider portal as well as the way you close member risk and quality care gaps. Starting January 20, 2025 these resources will be available to you via Availity Essentials.
If you are new to Availity Essentials, getting your Essentials account is the first step toward working with Coordinated Care on Availity.
Getting started: Designate an Availity administrator for your provider organization
Your provider organization’s designated Availity administrator is the person responsible for registering your organization in Essentials and managing user accounts. This person should have legal authority to sign agreements for your organization.
HOW DOES THIS IMPACT ME? | WHAT IS MY NEXT BEST STEP? |
|---|---|
I am the administrator. I am the designated | Visit Register and Get Started with Availity Essentials to enroll for training and access other helpful resources. |
I am not the administrator. I am NOT the | Your designated Availity administrator will determine who needs access to Availity Essentials on behalf of your organization and will add user accounts in Essentials. |
I am not sure. I am not sure who | Share this information with your manager to help determine who will be the designated Availity administrator for your organization. |
If you are already working in Essentials, you can log in to your existing Availity Essentials account to enjoy these benefits for Coordinated Care members beginning January 20, 2025.
Check out some of the time-saving tools that come with an Availity Essentials account:
- Verify member eligibility and benefits, submit claims, check claim status, and submit authorizations.
- Look for additional functionality in Coordinated Care’s payer space and use the heart icon to add apps to My Favorites in the top navigation bar.
- Save provider information in Essentials and auto-populate it to save time and prevent errors.
- Look for additional functionality in Coordinated Care payer space on Essentials and use the heart icon to add apps to My Favorites in the top navigation bar. Our current secure portal will still be available for other functions you may use today.
- Access Manage My Organization to save provider information. You can then auto-populate that information repeatedly to eliminate repetitive data entry and reduce errors.
Please note that all features on both provider portals (Coordinated Care – Medicaid & Marketplace and Wellcare – Medicare) will remain available after January 20, 2025.
It’s also time to say “goodbye” to mailed and faxed charts, and “hello” to digital clinical management. Risk Condition Validation (RCV) and Clinical Quality Validation (CQV) are time-saving apps on Availity Essentials that transform the way you close member risk and quality care gaps. With an integrated workflow, pre-populated forms, document upload, status tracking, and more — RCV and CQV are entirely digital from start to finish.
The RCV and CQV work queues can be located under the Clinical tab in the Essentials menu bar. If you’re unable to see the apps, your Availity administrator will need to assign you the Clinical Risk and Quality role on Essentials.
RCV serves as a valuable pre-service tool that provides insight into historical diagnosis data and suspected conditions identified by Coordinated Care. It’s also a new channel of submission for the Continuity of Care (CoC) Program.
We're excited to welcome you to Availity Essentials, helping you transform the way you impact patient care with Coordinated Care. If you need additional assistance with your registration, please call Availity Client Services at 1-800-AVAILITY (282-4548). Assistance is available Monday through Friday, 8 a.m. – 8 p.m. ET. For general questions, please reach out to your Provider Engagement rep.
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Quality
Medicaid Quality
Adult ASAM Criteria 4th Edition has been released
From the Washington State Health Care Authority: per SB 6228, our state will be transitioning to the updated ASAM Criteria in January 2026.
Thanks to legislative support and State Opioid Response dollars, we have partnered and contracted with Train for Change to offer an array of free training opportunities virtually over the next 18 months.
The trainings are offered in three tiers:
Tier 1 is called The Evolution of The ASAM Criteria: What’s New in the Fourth Edition.
This is a great training for a broad audience who works in the field and wants a consolidated overview of the ASAM updates. The tier 1 training is for anyone and everyone in the behavioral health field.
Tier 2 is a prerequisite for the tier 3 training and is called Two-day ASAM Criteria Fourth Edition Skill-building Training. The tier 2 training will benefit clinicians who are newer to the field or are SUDPTs who would benefit from an in-depth course.
Tier 3 is called Implementation, Improvement, Sustainability and Coaching of the ASAM Criteria, A “How To,” Science Based Approach. The tier 3 training is designed for for clinical supervisors, directors, administrators, and decision makers who play a key role in implementation and ongoing support of adopting the changes within their organization.
How do I sign up for ASAM trainings?
- Read through the 4th edition ASAM manual FAQ.
- Select the training that you want to attend.
- Click on the link for the training that you want to attend.
- Sign up using the email address for the location where you will attend the virtual training.
- Once registered, you will receive an email confirmation.
Return to School: Who can Provide EPSDT Well-Child Checkups?
- Physicians and Resident Physicians
- Naturopathic Physicians
- Advance Registered Nurse Practitioners (ARNPs)
- Physician Assistants (PAs)
- Registered Nurses working under the guidance of a Physician or ARNP may also perform EPSDT well-child checkups.
- Key takeaway for Metric Year 2025: Removal of telehealth visits from numerator.
Return to School: Well-Child Outreach:
- Children have returned to school this fall. It is time to reach out and conduct catch up immunizations and well-childcare. For more information, click here.
- Retired HEDIS MY2025 measures to include:
*CIS, will be CIS-E
*IMA, will be IMA-E
*CCS, will be CCS-E
*AMM
Breast Cancer Screening
Does your patient have any of these risk factors? They may need to be assessed for early onset Breast Cancer:
- Thoracic radiation between ages 10 and 30.
- Lobular carcinoma in situ or atypical hyperplasia
- Breast or ovarian cancer
Breast cancer screening guidelines for women chart provided by the CDC.
Wellcare Quality
September highlights Suicide prevention and healthy aging. According to the National Institute of Mental Health, research shows that mental illnesses are common in the United States, affecting tens of millions of people each year. Estimates suggest that only half of people with mental illnesses receive treatment.
For anyone in crisis, there are options available to help them cope. Call or text the 988 Suicide & Crisis Lifeline at any time to connect with a trained crisis counselor. For confidential support available 24/7 for everyone in the U.S., call or text 988 or chat at 988lifeline.org, or visit National Institute of Mental Health's website. #shareNIMH
For Septembers highlighted health awareness topics, visit the Office of Disease Prevention and Health Promotion (ODPHP). You can direct your patients to a customized check list for healthy aging tips and tracking here.
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Pharmacy
Wegovy Coverage Reminder
Wegovy requests for the prevention of major adverse cardiovascular events in obese or overweight patients need to be submitted to the Health Care Authority (HCA) Fee-for-Service (FFS) Program.
The FFS Program can be reached at the following Prior Authorization Phone Number: 1-800-562-3022 Extension: 15483.
Appropriate Use of GLP-1 Agonists
GLP-1 agonists have become part of the standard of care in the treatment of Type II Diabetes according to the American Diabetes Association (ADA) guidelines.1 We would like to make you aware of the coverage and clinical considerations. The ADA now recommends other medications (including GLP-1 agonists) with or without metformin based on glycemic needs, are appropriate initial therapy for individuals with type II diabetes with or at high risk for atherosclerotic cardiovascular disease, heart failure, and/or chronic kidney disease1.
Inappropriate prescribing of drugs like Ozempic and Mounjaro for treatment of obesity alone has contributed to shortages of these products for patients with Type II diabetes.2,3 While these products have proven to be effective for their respective indications, they are not without side effects/adverse reactions. The most common side effects are gastrointestinal-related, including loss of appetite, nausea, vomiting, and diarrhea. Additional issues have been identified with patients needing surgery when taking these medications. Due to the delayed gastric emptying feature of these drugs, it has been reported (at least anecdotally) that patients may have increased risk of regurgitation and pulmonary aspiration during general anesthesia and deep sedation3. As a result, the American Society of Anesthesiologists have set guidelines for the holding GLP-1 agonists prior to elective procedures4.
Some of these products, when coverage is available, may require a prior authorization (PA). We have noted, in recent months, many requests for GLP-1 agonists (particularly Ozempic and Mounjaro) that appear to be intended for use outside of the FDA-approved indications for the particular product. Coordinated Care will be actively monitoring and reviewing PA requests to ensure these medications are used only per their FDA-approved indications. Requests for documentation to substantiate attestations made in the PA request process may be required. It is also important to note that coverage of the products with weight loss indications are not covered by all plans as treatment of obesity is an excluded benefit for many plans.
These products are available in a number of different forms and product names with varying FDA-approved indications (see Table below).
| Medication | FDA Approved Indication | Dosing Frequency/Route |
|---|---|---|
| DIABETES | ||
| Dulaglutide (Trulicity) | Type II DM and pediatric patients ≥10 years of age with type 2 DM; reduction of cardiovascular mortality due to major cardiovascular events (MACE) in type II DM patients with established CV disease or multiple CV risk factors | Once weekly SQ injection |
| Exenatide, extended-release (Bydureon BCise) | Type II DM, pediatric patients ≥10 years of with type 2 DM. | Once weekly SQ injection |
| Exenatide (Byetta) | Type II DM | Twice daily SQ injection |
| Liraglutide (Victoza) | Type II DM and pediatric patients ≥10 years of age with type 2 DM; reduction of CV mortality, non-fatal MI, or non-fatal stroke in persons with Type II DM and established CV disease | Once daily SQ injection |
| Lixisenatide (Adlyxin) | Type II DM | Once daily SQ injection |
| Semaglutide (Ozempic) | Type II DM; reduction of CV mortality, non-fatal MI, or non-fatal stroke in persons with Type II DM and established CV disease | Once weekly SQ injection |
| Semaglutide oral (Rybelsus) | Type II DM; | Once daily tablet |
| Tirzepatide (Mounjaro) | Type II DM | Once weekly SQ injection |
| OBESITY | ||
| Liraglutide (Saxenda) | Obesity and pediatric patients ≥12 years of age with body weight >60 kg and an initial BMI corresponding to ≥30 kg/m2 for adults (obesity) by international cut-offs (Cole Criteria). | Once daily SQ injection |
| Semaglutide (Wegovy) | Obesity and pediatric patients ≥12 years of age with an initial BMI at the ≥95th percentile standardized for age and sex; risk reduction of major adverse cardiovascular events (cardiovascular death, nonfatal MI, nonfatal stroke) in adults with established cardiovascular disease and either obesity or overweight. | Once weekly SQ injection |
| Tirzepatide (Zepbound) | Obesity | Once weekly SQ injection |
*Covered and preferred products may vary by health plan or product. Please check the individual health plan website for specific coverage details.
References
- American Diabetes Association (ADA) Standards of Care in Diabetes – 2024.
- Semaglutide Injection
- Tirzepatide Injection
- American Society of Anesthesiologists Consensus-Based Guidance on Preoperative Management of Patients (Adults and Children) on Glucagon-Like-Peptide-1 (GLP-1) Receptor Agonists
Evolent Update-Medical Oncology
Effective for dates of service on or after 1/1/2025, prior authorization requests for the following new HCPCS codes need to be verified by Evolent.
| HCPCS | Generic Name | Brand Name | PA Required |
|---|---|---|---|
| J3590 | FILGRASTIM-TXID INJECTION | NYPOZI | Yes |
| J3590 | CROVALIMAB-AKKZ INJECTION | PIAKSY | Yes |
| J3590 | ECULIZUMAB-AAGH INJECTION | EPYSQLI | Yes |
| J8999 | LAZERTINIB ORAL | LAZCLUZE | Yes |
| J8999 | VORASIDENIB ORAL | VORANIGO | Yes |
| J9999 | DENILEUKIN DIFTITOX-CXDL INJECTION | LYMPHIR | Yes |
Participating providers should submit oncology/supportive drug authorization for members through Evolent.
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Clinical Policy Updates
Only one policy update was approved as part of our regular monthly review in August.
Due to new benefits effective January 1, 2025, the following policy will be effective January 1, 2025:
| Policy Number | Policy Title | Line of Business |
|---|---|---|
| CP.BH.100 | Allergy Testing | Ambetter |
The below policies were previously announced as revised effective on the date noted. You will find the policies posted on the policy site.
| Policy Number | Policy Title | Effective Date | Line of Business |
|---|---|---|---|
| CP.MP.176 | Outpatient Cardiac Rehabilitation | 10/1/24 | Ambetter |
| CP.BH.201 | Deep TMS for OCD | 10/1/24 | Ambetter |
| CP.MP.69 | Intensity-Modulated Radiotherapy | 11/1/24 | Apple Health & Ambetter |
| CP.MP.107 | Durable Medical Equipment (DME) and Orthotics and Prosthetics Guidelines | 11/1/24 | Apple Health & Ambetter |
| CP.MP.146 | Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins | 11/1/24 | Ambetter |
| WA.CP.MP.522 | Varicose Vein Treatment | 11/1/24 | Apple Health |
| CP.MP.184 | Home Ventilators | 11/1/24 | Apple Health & Ambetter |
| CG.CP.MP.01 | ID Respiratory Lab Testing | 11/1/24 | Apple Health & Ambetter |
| CG.CP.MP.02 | ID Multisystem Lab Testing | 11/1/24 | Apple Health & Ambetter |
| CG.CP.MP.03 | ID Dermatologic Lab Testing | 11/1/24 | Apple Health & Ambetter |
| CG.CP.MP.04 | ID Gastroenterologic Lab Testing | 11/1/24 | Apple Health & Ambetter |
| CG.CP.MP.05 | ID Primary Care Preventive Lab Testing | 11/1/24 | Apple Health & Ambetter |
| CG.CP.MP.06 | ID Vector-Borne and Tropical Diseases Lab Testing | 11/1/24 | Apple Health & Ambetter |
| CG.CP.MP.07 | ID Genitourinary Lab Testing | 11/1/24 | Apple Health & Ambetter |
| CP.MP.93 | Bone-anchored hearing aid | 12/1/24 | Apple Health & Ambetter |
| CP.MP.129 | Fetal Surgery in Utero for Prenatally Diagnosed Malformations | 12/1/24 | Apple Health & Ambetter |
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Apple Health Core Connections (AHCC)
Coordinated Care is honored to provide the health insurance plan (Apple Health Core Connections) for youth in foster care, youth have returned home to their parents, youth who have been adopted from foster care or placed in a guardianship, young adults who have aged out of the foster care system, and Unaccompanied Refugee Minors.
Our team of highly specialized care coordinators, care managers, health liaisons, and community educators are deeply committed to ensuring that each unique member receives high-quality physical and behavioral healthcare, as well as access to resources that support their healing, wellbeing, and journey into adulthood.
We are thrilled to share a few highlights from what we accomplished in 2023:
- We supported 21,762 youth and young adults! Total membership was 10% lower compared to 2022 due to the end of the public health emergency in June 2023, as well as the implementation of HB 1227 on July 1, 2023.
- Our care management team supported 21% more youth in 2023, completing 2,911 Care Coordination cases and 617 Care Management cases for members with more complex needs.
- We established two new Foster Care Centers of Excellence, Mt. Spokane Pediatrics and Northwest Pediatrics! And, we embedded care management into two COEs, Harborview and NW Peds.
- We partnered with Rising Strong (a holistic, family-centered drug treatment and housing program in Spokane which support families in staying together) by providing monthly, on-site classes for families and staff, covering a range of topics including the basics of AHCC, care coordination, value-added benefits, how families define what good health means to them, and a variety of our clinical trainings.
- We partnered with WA legislators and community organizations to pass HB 1188 which expands services to children in foster care with developmental disabilities.
To receive the full 2023 AHCC report or to inquire about becoming a Foster Care Center of Excellence, email Katherine.Ferguson@CoordinatedCareHealth.com.
Thank you for transforming the health of youth impacted by the child welfare system!
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Training/Education
Trauma 101 What is Trauma exactly? The term is used constantly, but not always understood. The training answers this question by defining trauma, how trauma affects children, and what caregivers and professionals can do to assist youth. The presentation will heighten the participant's awareness of children’s cues so they will know what to expect and how to respond when a child experiences trauma triggers. Thursday, Oct. 3 2pm – 2:30pm Register here.
Trauma and Food: What is the connection? This webinar will discuss the reasons behind food related concerns and is designed for those treating, supporting, and caring for children who have experienced trauma and may now have "quirky" eating habits, including food hording, stealing, or overeating. We will discuss how trauma affects childhood development and behaviors, as well as offer practical and easy ideas to help regarding food behaviors. Thursday, Oct. 10th 1pm – 3pm Register here.
Naloxone and Fentanyl: A detailed discussion Naloxone has become a popular item for folks to carry and use in case of an Opioid overdose in users, but many do not really know what it does or the best way to use it. In addition, the Opioid Fentanyl has grown in popularity for youth and adults, and it is often added to other drugs unbeknownst to the user, which makes it even more dangerous. Learn more about the history of Fentanyl in this training, details of how to use Naloxone, where to obtain it, and recommendations on how to provide assistance. Content developed by Mark Varela, SUDP, Addictions Systems of Care Liaison with Coordinated Care When: Tuesday, Oct. 15th 1pm – 3pm Register here.
Trauma Informed Care: Dealing with Feelings & Behaviors Trauma tends to create big feelings that children don’t know what to do with, and so what they don’t “talk out, they act out.” This presentation helps explain the links between feelings and behaviors and provides suggestions to help professionals and caregivers understand and modify problem behaviors. Training developed by the National Child Traumatic Stress Network (NCTSN) Tuesday, Oct. 22nd 1pm – 3pm Register here.
The Lost Boys - The Forgotten Victims of the Child Abuse Material Industry training is designed as an advanced level training for direct care staff and field staff working with Commercial Sexually Exploited Children (CSEC) and trafficking survivors. We will be discussing aspects of the child abuse material industry that are too often overlooked… boys: The Forgotten Victims. We will hear the stories and voices of male youth survivors in this training on the commercialized aspects of the child abuse material industry, enhance your knowledge base on trafficking, discuss myths & facts, current trends, and step inside the experiences of the forgotten victims themselves. Monday, Oct. 28th 10am – 1 pm Register here.