February 2015

Read the February 2015 issue of Provider News.

From the Chief Medical Officer, Karen Boudreau, MD

This is our first issue of an all-electronic Provider News, and I’m happy to be able to share it with you. Since the vast majority of providers have email and Internet access, an e-newsletter is both a practical and efficient means of communicating. Of course, we’ll continue to archive all issues of Provider News.

This issue is packed with valuable administrative and clinical information, including articles ranging from how you now can confirm online if a service requires prior authorization to how you can be more effective in helping your patients who smoke to quit.

To help ensure accurate and timely claims processing and payments, you’ll find an article describing an updated list of services designated for coverage only in the outpatient setting – we’ve uploaded the list to bmchp.org. We hope this will help to reduce administrative burden for you and your staff.

You should also make sure to read the article about the MassHealth (Medicaid) eligibility redetermination period currently underway. This is particularly important since enrollment can have a major impact on your practice. We look forward to partnering with you to make sure your patients continue to have access to BMC HealthNet Plan.

Every day we at BMC HealthNet Plan value the care you deliver to our members – thank you for your ongoing support.

Karen Boudreau, MD
Chief Medical Officer

Outpatient Services: Coverage for Certain Services Only in the Outpatient Setting

We have posted a list of all services designated for coverage only within the outpatient setting.

Beginning with March 9, 2015 dates of service, certain services on the outpatient-only list will be covered only when performed in the outpatient setting. If an inpatient setting is needed for a service that appears on the outpatient-only list, you must submit a Request for Prior Authorization to us, including all clinical documentation that supports the need for inpatient level of care. Medical necessity review will be completed based on your documentation.

Please review Network Notification #M-155 for more detailed information.

State Requires MassHealth Enrollees to Submit New Applications for Coverage

The Affordable Care Act requires states to review Medicaid eligibility every 12 months. MassHealth has resumed its annual Medicaid renewal process after suspending it in late-2013 because of system issues. Over one million MassHealth enrollees must submit new applications for health benefits this year so the state can determine if they still qualify for coverage. Those who fail to apply will lose their coverage. (MassHealth enrollees who already applied through the new Health Insurance Exchange starting this past November do not need to have their eligibility redetermined at this time.) During the last 30 days the state has sent renewal notices to over 297,000 households (representing over 504,000 MassHealth members) informing them that they must submit new applications.

We encourage you to talk to your MassHealth patients about the urgency of renewing their membership on time. We can send you a list of your BMC HealthNet Plan patients who require renewal – just call your dedicated Provider Relations Consultant.

Although the notices from the state include a renewal date, we recommend that members apply as soon as possible and no later than March 15 to be safe. Below are general application deadlines to use as a reference.


Member Group Receiving Renewal Notice Application Deadline
Households who renewed online last year March 15
Households with MassHealth Standard or Family Assistance March 23
Households with MassHealth CarePlus March 29

The fastest way to reapply for coverage is online through MAhealthconnector.org. Paper applications can also be submitted; copies of those applications were included in most renewal notices and are also available at MAhealthconnector.org. Or members may call the MassHealth Customer Service Center at 800-841-2900 (800-497-4648 for the hearing impaired) for information and direction. Navigators and Certified Application Counselors will continue to be available for in-person help, and a full list can be found MAhealthconnector.org/help-center.

The renewal process for the remaining 500,000 MassHealth members will be similar and will take place during this summer.

Online Help Available for Confirming if Prior Authorization is Required

Now you can check whether a particular service requires prior authorization by going to the Authorizations tab. You and your staff will save valuable administrative time, and we hope this will make your experience with us easier and more efficient.

To access this online lookup, click on the Authorizations link – this will lead you to the Prior Authorization Requirements page and the link for determining if prior authorization is necessary for a particular service, procedure or prescription drug. We encourage you to read the introductory information to learn the scope of this new tool and the other resources available to assist you.

Please remember that all elective inpatient admissions require prior authorization.

We are in Central and Western Massachusetts!

BMC HealthNet Plan delivers managed care coverage across most of Massachusetts, including the Central and Western areas of the state. As a strong organization and industry leader, we'll continue to provide access to high quality affordable healthcare in 2015 and beyond. Our members receive their care from a large network of healthcare providers, and we are pleased to collaborate with a number of hospitals furnishing health care services to our members in those regions:


  • Clinton Hospital/UMass Memorial Health Care


  • Marlborough Hospital/UMass Memorial Health Care


  • Health Alliance Hospital/UMass Memorial Health Care


  • Cooley Dickinson Hospital


  • MetroWest Medical Center


  • Athol Memorial Hospital


  • Heywood Memorial Hospital


  • Berkshire Medical Center

Great Barrington

  • Fairview Hospital


  • Harrington Memorial Hospital



  • Holyoke Medical Center


  • Noble Hospital


  • Health Alliance Hospital/UMass Memorial Health Care


  • Saint Vincent Hospital
  • UMass Memorial Medical Center

Physician Advisory Council Provides Valuable Input on a Variety of Issues

BMC HealthNet Plan has established a Physician Advisory Council that meets quarterly. The council includes a broad range of provider types reflective of the Plan’s membership. Our goal is for the council to actively participate in and provide feedback on projects, in addition to sharing provider perceptions on our quality initiatives and ongoing operations.

We are proud to have the following Physician Advisory Council members: Scott Early, MD, Lynn Community Health Center; Joan Kross, MD, Tufts Medical Center; Fran Markle, MS, LMHC, High Point Treatment Center; Julita Mir, MD, Dorchester House MultiService Center; Julie Mottl-Santiago, CNM, MPH, Boston Medical Center; Richard Schuman, MD, Riverbend Medical Group; Ali Tural, MD, Tural Pediatrics; Steven Winn, PhD, Behavioral Health Network, Inc.

Affordable Care Act Section 1202 Payments Ended December 31, 2014

As a reminder, we implemented Affordable Care Act Section 1202 enhanced rates for calendar years 2013 and 2014. On December 31, 2014 these enhanced payments expired. Providers who were receiving enhanced rates are now receiving the standard BMC HealthNet Plan physician rates for Medicaid members for dates of service January 1, 2015 and going forward.

CAQH ProView™ is Coming

More than 1.2 million healthcare providers trust the CAQH® Universal Provider Datasource® (UPD) as the premier resource for self-reporting personal and professional information to payers, hospitals and health systems. CAQH is making significant improvements to UPD, including changing the name of this next generation UPD to CAQH ProView™ to reflect these improvements and enhanced functionality. Scheduled to launch by mid-March, CAQH ProView will be faster and more intuitive to use. That means time savings for you.

Provider Benefits

CAQH has incorporated feedback from provider and health plan focus groups into the development of CAQH ProView. A range of new features will make it easier for providers to update data, reducing the time and resources necessary to submit accurate, timely data to organizations that require that information. Features include:

  • Complete and attest to multiple state credentialing applications in one intelligent workflow design.
  • Upload supporting documents directly into CAQH ProView to eliminate the need for manual submission and to improve the timeliness of completed applications.
  • Review and approve Practice Manager information before data are imported.
  • Receive more-focused prompts and real-time validation to protect against delays in data processing.
  • Self-register with the system before a health plan initiates the application process.

CAQH ProView will continue to be available to providers free of charge. In addition, all completed UPD applications with current attestations will automatically migrate into CAQH ProView.

You will need an email address to use CAQH ProView. If CAQH does not have one on file for your practice, you should enter it now in your current UPD account to ensure you receive all updates and information about the transition.

To enter an email address:

  • Login to your UPD account.
  • Click on “Edit Account.”
  • Enter a valid email address.
  • Change your “Contact Method” from FAX to email.

Visit caqh.org/ProView-Provider-Overview.php to learn more.

How to Report Fraud, Waste and Abuse

In the normal course of operations, BMC HealthNet Plan has procedures and systems in place to help detect, prevent, correct and/or recover monies for any instances of fraud, waste and abuse (FWA). This applies to provider, member, employee and vendor or contractor FWA.

As a healthcare provider, you may discover questionable provider or vendor billing or other suspect practices (for example, member card sharing). Please refer these matters to us through one of the methods below. If you’re unsure whether or not a behavior or action would be considered an instance of FWA, we are available to discuss it with you.

  • Call our Compliance/Fraud Hotline: 1-888-411-4959
  • Email our Special Investigations Unit: FraudandAbuse@bmchp.org
  • Fax our Special Investigations Unit: 1-866-750-0947
  • Postal mail us:
    BMC HealthNet Plan
    ATTN: Special Investigations Unit
    Two Copley Place, Suite 600
    Boston, MA 02116

2015 HEDIS Project Begins

As an NCQA-accredited health plan, BMC HealthNet Plan is required to participate in an annual HEDIS project to measure the quality, access and use of services by our members during the previous year. As a result, we are launching our annual project with a chart review component that will be ongoing through mid-April.

Provider groups that are part of the project can expect to be contacted so we can obtain chart information about pertinent services delivered to the members who are part of the sample. Member samples are randomly selected for various NCQA HEDIS preventive and chronic disease measures. Depending on the volume of charts, we will ask providers to fax or postal mail the records to our Boston office, or we will offer an onsite visit by one of our reviewers. If providers wish, they may send chart information through encrypted, password protected electronic distribution methods. We are also willing to access your electronic medical record system either onsite or remotely.

Please be assured that we will do whatever we can to minimize disruption to provider practices during this process.

We Can Work Together to Improve Quality

Don’t forget that your contract with us requires your cooperation with all quality improvement activities we undertake. These can include disease management programs, adopted clinical practice guidelines, medical record reviews, focus studies, provider profiling and performance monitoring. It is also important that you allow us to review and use provider/practitioner performance data to inform and ensure the success of all quality improvement programs.

Affordable Care Act Requirements: Grace Period Required for Delinquent Premium Payments

As required by the Affordable Care Act (ACA), Qualified Health Plan members who purchase coverage through the Health Connector and who receive federal subsidies must be given a 90-day grace period after the premium payment deadline to make the required payments. During this 90-day period, health plans are not allowed to terminate coverage for non-payment, so those members would still be indicated as eligible for coverage when you conduct eligibility determinations. If they do not pay their premiums by the end of the 90-day grace period, their coverage will be retroactively terminated back to the first day of the second month of this 90-day period. Please understand that this federal requirement may directly affect your payments for covered services.

In accordance with ACA, we will continue to process and pay claims for covered services you deliver during the three month grace period, but will notify you accordingly that the second- and third- month claims are subject to later denial and payment retraction if the member does not pay his or her premium by the end of the grace period. You’ll receive the notification in your Remittance Advice and the Electronic Remittance Advice (835). If the member does not pay the premium by the end of the grace period, once we are notified by the Health Connector, we will terminate the member retroactively to the first day of the second month of the 90-day period. As a result, we will retract payment for all claims for services rendered during the second and third months of the 90-day period. Claims that were paid for services provided during the first month of the grace period will remain paid.

Please note that these requirements do not apply to our MassHealth members.

For additional important details, please go to section 9.3 of our Provider Manual.

Free Literature Racks Available

Providers and community based organizations can receive free co-branded Lucite literature racks to hang in waiting rooms, exam rooms or any other appropriate high traffic area. The racks are available in different sizes and configurations, can be wall mounted or placed on tabletops, and if you need assistance with hanging a rack, we can also provide that service free of charge.

For details or to place an order, please email Julie.Nations@bmchp.org.

Providers Have Influence on Prenatal Care Initiative

One of the focuses of our 2014 prenatal and postpartum care initiatives was encouraging providers to submit to us ACOG or other prenatal assessment forms. As a result, there were a number of instances when our receiving the forms directly impacted the care of pregnant members. In one case, a prenatal form helped our Sunny Start care manager offer emotional and medical support to a member who lost a current pregnancy in addition to having a history of lost pregnancies. This was possible because a provider submitted the ACOG/prenatal assessment form to us. From these forms we can identify high-risk pregnancies and provide appropriate care coordination from our Sunny Start program care managers.

Because of the positive impact, we will continue this initiative. For each form submitted, providers will receive a $25 reimbursement fee. For more information, please click here.

Help Ensure Success when Prescribing Antidepressants

Managing patients who take antidepressants can be challenging, so we want to offer you some support with the following practical tips that can help increase successful treatment and compliance, and foster communication between you and those patients.

  • Make sure your patient has clear instructions about the medication, especially if it’s new. You can even ask the patient to repeat back to you the information such as what the medication is for, how and when to take it and how long to take it.
  • Your patient needs to understand that it may take several weeks before the antidepressant begins to work, and that he or she should not stop taking it without first consulting you.
  • Antidepressant users can experience side effects ranging from mild to severe, so make sure your patient understands what to look for and when to contact you if there is a problem.
  • Suggest that he or she use a pill box to ensure the medication is taken every day at the same time.
  • There are instances when antidepressant dosages need to be adjusted or changed, or medication added. Be sure to discuss this with your patient at the outset of a course of treatment.
  • Always schedule a follow-up visit to monitor your patient’s progress. You should make this appointment at the end of the initial appointment.
  • Your staff can also offer reminders to your patient about the proper use of antidepressants and what the patient can expect.
  • Recommend that your patient asks his or her pharmacy to sign up for automated reminders about refilling their medication.
  • If you prescribe an antidepressant to a pregnant patient, make sure she is comfortable with the information and understands the medication is safe to take.

If you have BMC HealthNet Plan members you believe would benefit from behavioral health services or behavioral health care management, please contact Beacon Health Strategies (our behavioral health partner) at 800-444-5155. For additional information, please review the guideline endorsed for Adult Depression in Primary Care.

Do your patients really need antibiotics for respiratory tract infections?

Public health professionals, doctors and patients are increasingly concerned about the overuse of antibiotics. According to research as far back as 1997*, more than half of the antibiotics prescribed for acute respiratory infections – such as acute bronchitis – are unnecessary because the infection is viral.

In Massachusetts, antibiotics are still over-prescribed for acute bronchitis. According to statewide information published by the Massachusetts Health Quality Partners (MHQP), antibiotics are used appropriately in only 24% of cases of acute bronchitis**.

So what do you do when patients with acute viral bronchitis ask for antibiotics? You may need to tell them that:

  • When acute bronchitis is from a virus, antibiotics will not help.
  • Antibiotics can cause harm if used when not needed because bacteria can become resistant and develop “super bugs.”
  • Antibiotics can cause side effects such as headaches and rashes.

To help you educate your patients about proper antibiotic use, the Centers for Disease Control and Prevention offers free tools, including a viral prescription pad. You can link to the information from our website.

*Gonzales, Ralph MD MSPH, Steiner, John MD MPH, Sande, Merle MD. “Antibiotic Prescribing for Adults with Colds, Upper Respiratory Tract Infections, and Bronchitis by Ambulatory Care Physicians.” The Journal of the American Medical Association. September 17, 1997. Volume 278. Number 11.

**“Medication Management: Correct Use of Antibiotics for Acute Bronchitis.” Massachusetts Health Quality Partners. Web. Quality Reports. http://mhqp.org/quality/clinical/cqMASumm.asp

HPV vaccine is safe and can save lives

According to the Centers for Disease Control, each year nearly 17,000 women and 9,000 men are affected by human papillomavirus (HPV)-related cancers. That is why BMC HealthNet Plan supports the Massachusetts Department of Public Health recommendation for administering HPV vaccinations for preteen girls and boys, ages 11 or 12, before they become sexually active. Girls and young women, ages 13 through 26, should also get HPV vaccines if they have not received any or all doses when they were younger. Studies continue to show that the vaccines are safe, so providers caring for young people should discuss this life-saving topic with parents/guardians.

How You Can Help Your Patients Control Their Asthma

Teaching your patients who have asthma how to identify and avoid triggers can help prevent asthma attacks. Some common triggers include:

  • Pollen
  • Mold
  • Certain foods (e.g., milk, peanuts)
  • Hair
  • Pets/animal fur/dander
  • Dust mites
  • Cigarette smoke
  • Perfume, household cleaners

Make sure your patients know their triggers and understand that keeping away from them is key to staying well.

Asthma Control Test

To help your patients monitor their asthma, BMC HealthNet Plan and the American Lung Association recommend the asthma control test (ACT), a brief test that your patients can download, print and complete.  And make sure you review and discuss the results with your patients.

As always, please refer to the Asthma Clinical Practice Guidelines that we have endorsed. If you have BMC HealthNet Plan members with asthma whom you believe would benefit from care management, please contact us at 1-866-853-5241. We will conduct assessments for these members, develop an individualized care plan, and our care managers will provide educational materials and overall support.

Guidelines Endorsed

BMC HealthNet Plan has endorsed the following clinical practice guidelines:

  • National Heart Lung and Blood Institute (NHLBI) and National Asthma Education Prevention Program (NAEEP) asthma guidelines
  • Institute for Clinical Systems Improvement Prenatal Care Guidelines
    • Prenatal Care
    • Major Depression in Adults
    • Attention Deficit Hyperactivity Disorder
  • American Diabetes Association: Standards of Medical Care in Diabetes - 2015

These and all guidelines adopted by BMC HealthNet Plan can be found in the Patient Care section. If you do not have Web access, please contact your Provider Relations Consultant for copies.

Stop Smoking Help Available

We strongly support providers’ efforts at working with their patients to stop smoking. That’s why we recommend QuitWorks, a free, evidenced-based program developed by the Massachusetts Department of Public Health, and an all-inclusive resource for you to help engage your patients who smoke to kick the habit.

Remember, too, that we provide coverage for over-the-counter and prescription smoking cessation treatment. Our formulary is available on the Pharmacy page. Quantity limits may apply.

The information you need – including step-by-step instructions on what to do – is detailed on the QuitWorks website.

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