May 2016

Read our May 2016 issue of Provider News.

Program Focuses on Home Visits to Members with Asthma

According to the most recent statistics available from the Centers for Disease Control website, 17.7 million adults and 6.3 million children have asthma. In Massachusetts, over 475,000 adults and over 135,000 children experience this chronic illness. At BMC HealthNet Plan, over 19,000 members are being treated for asthma.

To help members who have asthma take control of their treatment and avoid hospitalizations, last fall we launched the Community Health Worker Asthma Program. Through this initiative, specially trained BMC HealthNet Plan Community Health Workers conduct home visits across Massachusetts to complete an Environmental Protection Agency (EPA) assessment of environmental triggers, conduct a medication inventory and discuss health issues the members may experience. In addition, members receive a copy of an Asthma Action Plan with instructions to complete it with their health care providers at their next office visits. To ensure clinical oversight, Nurse Care Managers work in tandem with the Community Health Workers, providing telephone care management. Nurse Care Managers also conduct personal visits with members, as needed.

According to Jeanmarie Javorski, RN, CCM, Manager of Care Management and the program’s developer, “A face-to-face meeting between the Community Health Worker and a member personalizes the entire approach to asthma treatment. This is crucial for a successful outcome, and it is an innovative strategy for a managed care organization.”

The program is open to any BMC HealthNet Plan member diagnosed with asthma. Members become involved in the program through a number of ways, including if they:

  • Are referred by a health care provider
  • Self-refer
  • Have been treated for asthma related symptoms with steroids
  • Have been hospitalized for asthma related symptoms

“Since last fall, we have conducted 32 home visits, so we are making great headway even though the program is still in its infancy,” said Ms. Javorski.

If you have a BMC HealthNet Plan patient with asthma, you can direct the patient or his/her family member to call our Care Management line at 866-853-5241 for information about the program. Or you may call us with the member’s information and a nurse will conduct the initial member outreach.

Interest on a National Level

Ms. Javorski recently was invited to participate in the National Asthma Leadership Roundtable sponsored by America’s Health Insurance Plans (AHIP) in partnership with the EPA. The roundtable included health plan leaders and federal partners who discussed implementing home-based asthma management. AHIP and the EPA are collaborating on a three-year agreement to identify and promote health plan strategies for managing asthma and reducing exposure to environmental asthma triggers.

Billing and Coding Tips for HEDIS® 2016 Available

Now you can easily locate and use the appropriate codes for common health care services by accessing the Healthcare Effectiveness Data and Information Set (HEDIS) Billing & Coding Guide. In it you’ll find all applicable codes to document office visits, preventive health services and other common health care services. This important resource also may help reduce the need for medical record chart reviews during the annual HEDIS data collection season.

Appropriate coding helps with:

  • Maximizing provider reimbursement
  • Processing claims quickly and efficiently
  • Identifying and addressing care gaps for patients
  • Improving the accuracy of the care gap reports available on our provider portal

Antidepressant Medication Management Member Outreach Program Helps With Adherence

Members who are newly prescribed antidepressants should take advantage of the Antidepressant Medication Management (AMM) Member Outreach Program. Working with our behavioral health partner, Beacon Health Strategies, the program’s goal is to improve medication adherence.

The AMM Member Outreach Program is a quality improvement program administered by Beacon’s Psychotropic Drug Intervention Program. Specially trained health coaches provide telephone member outreach and therapy coaching services to enrolled members who may benefit by having a successful outcome associated with improved adherence for their newly prescribed antidepressant medication. Medical providers can refer and enroll eligible members in this complimentary program.

To be eligible, members must:

  • Be at least 18 years old and currently eligible for BMC HealthNet Plan coverage
  • Have been recently prescribed an antidepressant and had the prescription filled
  • Have been diagnosed with major depression during the 60 days prior through 60 days after the date the antidepressant was originally dispensed
  • Be starting a new course of prescription for an antidepressant medication in the immediately preceding 105 days from when the new prescription was filled

If you have questions about this program or requests for enrollment forms, please call 781-994-7572 or email.

Talking to Your Patients About Antidepressants

Given that antidepressant medication adherence can be a challenge, providers who prescribe these medications should reinforce some important messages:

  • Many antidepressants can take up to three months to take effect, so do not stop taking the medication if the patient isn’t feeling better right away.
  • Make sure the patient understands the importance of refilling the medication on time and taking the medication as directed.
  • These medications can have initial side effects that often wear off. However, make sure your patient knows that he or she should call you if the side effects are worsening or if the medication isn’t working after a certain period of time. This may mean adjusting, changing or supplementing the medication.

CAQH Revalidation and Re-attestation is Imperative

To ensure that your credentialing process is not delayed unnecessarily, we strongly encourage providers to revalidate all information in your CAQH account and re-attest that your application is complete.

Your CAQH ID is required to complete any new or updated HCAS forms submitted to BMC HealthNet Plan.

It is imperative that your correct credentialing contact information is updated in your CAQH profile in the event that we need additional information. For any applications that are missing information, we will hold your file for 60 days before withdrawing it from the credentialing process. If your application is withdrawn, you must reapply. This means you will be considered as a new applicant, which will delay your participation status.

When creating or updating a CAQH account, you must submit the following documents for both initial credentialing and re-credentialing:

  • Current Professional Liability Insurance or Face Sheet (Please ensure that the certification includes the provider's full name, or, if not the case, include a list of providers covered under the professional insurance policy.)
  • Current Curriculum Vitae (CV) / Work History in month and year format
  • Current attestation
  • Electronic re-attestation, as applicable

If you have any questions, you may contact us at

Please Communicate with Behavioral Health Providers

We're reminding primary care providers to communicate with our members’ behavioral health providers when those members are in treatment for medical and behavioral health reasons. An effective means of communications is the Combined MCE Behavioral Health Provider/Primary Care Provider Communication Form.

Electronic Funds Transfer Improves Cash Flow; No Waiting for Checks to Clear

Make sure that your provider office takes advantage of electronic funds transfer (EFT), a convenient and efficient option for claims payments. EFT permits an electronic direct deposit of your BMC HealthNet Plan claim reimbursements into a bank that you designate.

Advantages of EFT include:

  • Prompt payment – no waiting for checks to clear
  • Improved cash flow
  • No lost checks or postal delays
  • Administrative savings
  • Reduced paperwork
  • Secure payment environment

For more information about how to enroll in EFT, please call your dedicated Provider Relations Consultant or call the provider line at 888-566-0008.

You Can Prevent Medical Identity Theft

Taking steps to ensure that your patients are who they identify themselves as can help stop medical identity theft. A patient’s identity can easily be compromised when his or her health insurance card is lost or stolen and used by another individual.

To help avoid this situation, follow these practical tips to verify every patient’s identity:

  • Require every patient to present a photo ID and insurance card at every visit.
  • Make a copy of every patient’s driver’s license – or other legal photo ID – and insurance card and keep them in the patient’s medical record.
  • Please contact us if you suspect medical identify theft. Our confidential, toll free Compliance Hotline is available 24/7, 365 days per year: 888-411-4959.

Full Range of Health Care Services Available to SCO Plan Members

Our Senior Care Options plan for residents of Suffolk County, which was launched January 1, offers quality health care coverage to individuals ages 65 and older who qualify for Medicaid MassHealth Standard and also may qualify for Medicare.

Given the often specialized care that this population requires, we are fortunate to partner with exceptional health care providers. SCO members have access to the full range of health care services offered at Boston Medical Center, Tufts Medical Center, Carney Hospital, St. Elizabeth’s Medical Center and their associated providers.

Our SCO behavioral health, dental and durable medical equipment networks are statewide, but our SCO medical network is currently limited to Suffolk County. Please be aware that in the future we may expand our SCO plan to other areas of Massachusetts, and will contact our network medical providers directly at that time regarding contracting for SCO.

Although our SCO coverage is for residents of Suffolk County, we will continue to deliver to all our providers the excellent, dedicated support you have come to expect from us. For more information, please visit our SCO website,, or contact your dedicated Provider Relations Consultant.

Training for SCO-contracted Providers in Suffolk County

If you practice in Suffolk County and are contracted with us to furnish health care to our SCO members, you must complete the Model of Care training. All newly-contracted providers (and annually after that) are required to take the training, which is available online.

If you have questions about the training, please contact your dedicated Provider Relations Coordinator.

Is Imaging for Low Back Pain Always Necessary?

According to the Agency for Healthcare Research and Quality (AHRQ) guideline, imaging studies for low back pain are not warranted within the first six weeks of symptoms. Since low back pain is the one of the most common ailments and reasons for office visits, providers should remember that imaging studies do not improve health outcomes. Diagnostic imaging may be indicated for patients who, after taking a thorough medical history and conducting a physical exam, have severe neurologic symptoms or have suspicion of malignancy or infection.

In a meta-analysis of six randomized studies published in The Lancet, there was no difference in outcomes for patients who underwent imaging studies vs. those that received usual care without imaging.1

Uncomplicated low back pain is a self-limited condition, and most people with low back pain feel better in four to six weeks with or without imaging studies. The key to managing patients with low back pain is to help them return to their baseline. It is important to reassure them about your findings and why imaging studies are not indicated.

Consider encouraging your patients with low back pain to follow these self-care techniques:

  • Stay active with low impact exercise and walking.
  • Use heat to relax muscles.
  • Use over-the-counter medications to help relieve pain, such as acetaminophen, ibuprofen or naproxen.
  • When in bed, lie sideways or on your back.
  • Consider physical therapy.

Choosing Wisely, an initiative of the American Board of Internal Medicine (ABIM ) Foundation, offers patient information on managing low back pain.

1Chou, R et al. Imaging strategies for low back pain; systematic review and meta-analysis. Lancet. 2009;373:463-472.

Prenatal, Postpartum Incentive Programs Available to Providers and New Moms

Providers Reimbursed for Completed ACOG Prenatal Assessment Forms

Given the critical importance of prenatal care, BMC HealthNet Plan continues to offer a $25 reimbursement to all contracted OB/GYN and Family Health practitioners who return a completed ACOG (American Congress of Obstetricians and Gynecologists) Prenatal Assessment Form for each pregnant member after her first prenatal visit. This allows us to offer care management in a timely manner, and provides an opportunity to identify high risk members who could benefit from care management. Learn more.

Diapers Available to New Mothers

Any BMC HealthNet Plan member who has delivered a baby and has had her postpartum visit within 3 to 8 weeks after delivery can receive a free box of diapers. The member must have her OB/GYN or Family Health practitioner complete, sign and return a simple form at the time of the visit. To speed up the process, the provider can fax the form back to us during the member’s postpartum visit. Access the form and instructions.

Patients With Behavioral Health Issues? Resources Available for PCPs

Delivering behavioral health services in a primary care setting can help reduce the stigma and discrimination associated with mental health diagnoses. It’s also more cost-effective to treat common behavioral health disorders in primary care settings. Toward that end, Beacon Health Strategies, our behavioral health partner, has developed a toolkit to assist PCPs with diagnosing and treating mental health and substance use disorders. The conditions covered in the toolkit are:

  • Alcohol and other drugs
  • Anxiety
  • ADHD
  • Depression, adolescent depression and postpartum depression
  • Eating disorders
  • OCD
  • PTSD
  • Schizophrenia

The toolkit also contains forms allowing PCPs to share relevant patient information with other providers, including behavioral health providers, to facilitate better integration of care.

PCPs Get Assistance to Meet Needs of Youngsters with Behavioral Health Issues

If a PCP has a young patient with behavioral health problems, the Massachusetts Child Psychiatry Access Project (MCPAP) is available to provide real time telephone consultation with a child psychiatrist. MCPAP works with PCPs to help with conditions such as depression, anxiety disorders and ADHD. The MCPAP child psychiatrist can offer assistance with assessment, screening and diagnosis of behavioral health issues. MCPAP also can recommend treatment and referrals to community resources, and can assist with appointment scheduling.

All MCPAP services for pediatric or family physicians begin with a telephone call to the regional team in your area:

MCPAP Regional Teams

Western Massachusetts
Bay State Medical Center

Boston/Metro Region I
Massachusetts General Hospital

Central Massachusetts
UMass Memorial Medical Center

Boston/Metro Region II
Tufts Medical Center/Boston Children's Hospital

Northeast Region
North Shore Medical Center

Southeast Region
McLean Hospital Southeast

You can visit to see to which region your city, town or practice is assigned.

Diabetes Guidelines Endorsed

BMC HealthNet Plan has endorsed the American Diabetes Association 2016 Standards of Medical Care in Diabetes.

When you have patients with diabetes, it is important that you discuss self-management and diabetes control, with a focus on the following recommended screenings:

  • A1c test at least twice a year if the member’s A1c is in control, and quarterly if the member is not at target.
  • Screen for and treat diabetic kidney disease.
  • Dilated eye exam to screen for retinopathy. If retinopathy is not detected, the test can be administered every two years. Be sure the member has an eye care provider.
  • Hypertension/high blood pressure control
  • Evaluate for atherosclerotic cardiovascular disease and risks.
  • Consider aspirin therapy, ACE (Angiotensin Converting Enzyme) or ARB (Angiotensin Receptor Blockers).
  • Screen for depression and treat it accordingly.

View these and other guidelines endorsed by BMC HealthNet Plan. If you require a printed copy, please contact your dedicated Provider Relations Consultant.

Documentation Must Include All Required Elements

BMC HealthNet Plan’s Provider Audit and Special Investigation Department uses the 1995 CMS Documentation Guidelines for Evaluation and Management when verifying the appropriate documentation of services rendered and accuracy of coding. Per the guidelines, please ensure that your medical record documentation contains all required elements to support the visit level billed.

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