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Select News: March 2016

HEDIS® Spotlight: ADHD reminders

Once a provider has made an attention-deficit hyperactivity disorder (ADHD) diagnosis, please inform and remind the family and child about triggers and behavior management:

  • Encourage parents to set a routine, limit leisure time, track good behavior, and encourage a sport or hobby to help their child manage ADHD in addition to taking medication.
  • Educate the patient and family on the initial medication (titration) process, which may take some time, and the possibility of side effects such as decreased appetite or insomnia.
  • We strongly recommend a face-to-face follow-up visit to monitor any changes in height and weight within the first two to three weeks of the start of treatment.
  • For the first year of treatment, we recommend face-to-face visits every three months and then at least twice a year after that.

To refer a patient to a behavioral health professional, call Member Services at 1-888-276-2020 or the Rapid Response and Outreach Team at 1-866-899-5406.

Physician champion

We’d like to spotlight and thank Debbie Greenhouse, M.D., of Palmetto Pediatric and Adolescent Clinic for her participation and leadership in Pediatric Research in Office Settings (PROS), the practice-based research network of the American Academy of Pediatrics. PROS practices take part in large, population-based studies that increase our knowledge about issues pediatricians deal with daily. Recent PROS studies have addressed childhood obesity, ADHD management and teen smoking. “Participating in PROS studies and acting as the South Carolina chapter coordinator has allowed me to continue to participate in meaningful research while maintaining a busy office practice,” says Greenhouse. Upcoming studies will look at increasing immunization rates at the practice level and increasing flu vaccine rates by using text messages.

Covered benefits for members with diabetes

  • Diabetic education is a covered benefit for all members. No prior authorization (PA) is required if the provider is in network and diabetes patient education (DPE)-certified or a Department of Health and Environmental Control office. For current DPE providers, visit the Provider Search page and search for “diabetic program educator.”
  • Home health care: First Choice covers physician-ordered home health care when it’s determined medically necessary. Newly diagnosed members with diabetes may need skilled nursing visits for observation and assessment or teaching and training visits. PA is required after the sixth visit.
  • Dilated eye exams are covered and include refractions regardless of age. No PA is required.
  • Blood glucose meter (glucometer): Maximum of one of the below meters per year plus one meter for school if designated on the prescription.
    • ACCU-CHEK® Aviva Plus meter.
    • ACCU-CHEK® Nano SmartView meter.

For a full list of covered benefits, visit our website.

CLAS is in session

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Earn free continuing medical education (CME) and continuing education (CE) credits while learning about cultural competency in health care. Self-directed training courses help you learn to accommodate increasingly diverse patient populations and overcome challenges in caring for patients with low health literacy. Designed for physicians, physician assistants and nurse practitioners, these courses are available online through Think Cultural Health and the Centers for Disease Control and Prevention. Visit our website or contact Chris Welch, Select Health’s culturally and linguistically appropriate services (CLAS) coordinator.

Our Quality Improvement program works for you

First Choice has a Quality Improvement program dedicated to excellence in clinical and service areas important to you. Each year, we evaluate ways the plan can improve.

  • Member experience is a priority.
    We congratulate our providers on your efforts to improve First Choice member experiences. In our 2015 Consumer Assessment of Healthcare Providers and Systems (CAHPS®) child survey, sent to members annually, scores remained high in many areas, in part because of our combined efforts. Ninety percent of our members said they had good experiences with their personal doctors; 91 percent would recommend the plan. The survey identifies ways we can continue to improve; in 2016 – 2017, we will collaborate to improve the CAHPS composite, Shared Decision Making. Below is a snapshot of that composite:
    • 93 percent of members surveyed said doctor talked about reasons you might want to take a medicine.
    • 64 percent of members surveyed said doctor talked about reasons you might not want to take a medicine.
    • 72 percent of members surveyed said doctor asked you what you thought was best.
  • Patient experience improvement tips.
    • Develop patient education materials that explain the pros and cons of commonly prescribed medicines (asthma or high blood pressure medications, statins).
    • Discuss the benefits and risks of taking a medicine.
    • Discuss patient’s preference on what medication would be best.
    • If the patient is not getting positive results, discuss alternate medications.
    • Discuss why the patient may need to stop taking a particular medication.
    • Listen closely and explain things in an easy-to-understand way to ensure you address all the patient’s concerns.

Thank you for supporting our efforts to continuously improve care for our members, your patients. Information about our quality program, including CAHPS survey results, is on our website under View Quality Data (PDF). You can also email us at value@selecthealthofsc.com.

Drug updates

Visit our website for up-to-date pharmacy information, including changes approved by the Pharmacy and Therapeutics Committee, as well as:

  • Preferred drug list (PDL) updates.
  • New prior authorization criteria and procedures for submitting a prior authorization.
  • Pharmacy benefit restrictions or limitations.

Provider disputes

A provider dispute is an escalated verbal or written expression of dissatisfaction not resolved by previous inquiries. Usually, provider disputes are claims-related or administrative in nature and involve issues related to postservice payment reductions or denials. Select Health has streamlined the current provider dispute process by developing:

  • A one-level provider dispute system that aligns with South Carolina Department of Health and Human Services requirements.
  • A dedicated provider dispute system that documents and tracks all disputes.
  • A centralized mailing address for written disputes and supporting documentation:

Select Health of South Carolina
Provider Claims Disputes
P.O. Box 7310
London, KY 40742-7310

Visit our website for details.

New and current subscribers: Win $50

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We hold random monthly drawings for a $50 Amazon.com e-certificate for online subscribers. Subscribe here for a chance to win. Current subscribers are automatically included. We’ll notify March’s winner in April, so sign up now!