The Illinois Department of Healthcare and Family Services (HFS) has responded to three questions about the SMART Act mandated prior approval policy for medications that were asked during the most recent Illinois Health Connect Provider Network Subcommittee Meeting.
1. What is the turn-around time for pharmacy prior approvals?
HFS response: Currently, the Bureau of Pharmacy Services processes requests for prior approval within approximately one hour. Prior approval request decisions are not carried over to the next day unless the review staff is waiting on information from the provider.
2. Currently, prior approval requests to exceed the four prescription limit must be made by the prescriber. How is that handled if the prescriber is an ER physician?
HFS response: In the case of a script written by an ER physician, HFS would allow a prior approval request from a pharmacy. HFS is in the process of publishing a clarification on this issue.
3. What is the criteria for denial of a request to exceed the four prescription limit?
HFS response: If the drug is on the Four Prescription Limit Approvable Medications List, the request will be approved unless the reviewing pharmacist identifies the drug is duplicative of other drugs in the profile, or if it is being used inappropriately, in which case, the reviewing pharmacist will notify the prescriber of the denial. Update: HFS reported on November 16 that there is no longer an "approvable drug list." Prior Approval requests can be submitted and will be clinically reviewed for approval for any drug.
Tuesday, September 25, 2012
Tuesday, September 18, 2012
Payments issued for 2011 IHC Bonus Program
The Illinois Department of Healthcare and Family Services (HFS) and Automated Health Systems (AHS) are pleased to announce that more than $5.3 million in payments have been issued for the 2011 Illinois Health Connect Bonus Payment for High Performance Program.
All bonus payments were mailed this week to the payee address of each qualifying IHC Primary Care Provider (PCP).
PCPs can access the patient specific detail of their bonus payments via the IHC Provider Portal through the secure HFS MEDI System. A new feature this year is a column that lists the potential payment for each bonus measure, which shows what a PCP could have earned for that measure with a 100 percent score.
The bonus payments for care provided in 2011 were $25 per qualifying patient, per qualifying event. Providers with multiple IHC locations of service were eligible for independent bonuses at each location.
For more information on the IHC Bonus Payment, please call an IHC Quality Assurance Nurse, an IHC Provider Services Representative or the IHC Provider Services Help Desk at 1-877-912-1999, extension 3.
All bonus payments were mailed this week to the payee address of each qualifying IHC Primary Care Provider (PCP).
PCPs can access the patient specific detail of their bonus payments via the IHC Provider Portal through the secure HFS MEDI System. A new feature this year is a column that lists the potential payment for each bonus measure, which shows what a PCP could have earned for that measure with a 100 percent score.
The bonus payments for care provided in 2011 were $25 per qualifying patient, per qualifying event. Providers with multiple IHC locations of service were eligible for independent bonuses at each location.
For more information on the IHC Bonus Payment, please call an IHC Quality Assurance Nurse, an IHC Provider Services Representative or the IHC Provider Services Help Desk at 1-877-912-1999, extension 3.
Monday, September 17, 2012
High blood pressure is a silent killer
High blood pressure puts you at risk for heart disease, stroke, vision loss, and sexual problems in men. It is one of the leading causes of death in the United States. One in three Americans have high blood pressure, but only half of those have it under control.
So, what is high blood pressure?
As your heart pumps blood, the blood pushes against the walls of blood vessels. This force is called blood pressure. The higher your blood pressure is, the more the blood pushes on the the blood vessels, and the harder your heart has to work to pump blood to all of your body.
How do you know if you have high blood pressure?
To find if you have high blood pressure, visit your Primary Care Provider (PCP) at your medical home for a check-up. This is very important because high blood pressure has no symptoms. That is why it is called the silent killer.
If your PCP at your medical home tells you that you have high blood pressure, there are many ways you can help control it.
Choosing a healthy diet low in salt is a great start. An easy way to eat healthy is to divide your plate into four equal parts. Two parts should be filled with fruits and vegetables, preferably raw or steamed. Fill one part with protein, such as chicken breast. The last part is your starch, like a piece of whole wheat bread or brown rice. Avoid fried foods and sugary sweets.
Exercise helps you strengthen your heart, feel better, and reduce stress. Your PCP can guide you on appropriate exercise routines.
If you smoke, try to quit. Everytime you smoke, your blood vessels constrict, causing your blood pressure to rise even higher. If you need help quitting, call the Illinois Tobacco Quitline at 1-866-Quit-Yes. The call is free.
If blood pressure medicine is prescribed by your doctor, be sure to take it as prescribed. Ask your PCP or pharmacist for help if the directions are not clear to you. Make a plan to help you remember to take your medicine every day. Use a calendar and check off when you have taken your pill.
If you miss your dose, contact your PCP for instructions on what to do. If your PCP prescribes more than one medicine, write these medicines down in a chart, and check them off as you take them.
The American Heart Association offers a free medicine chart to make this easy for you. Be sure to take this chart with you when you visit any medical or dental provider.
Your PCP may order a blood pressure monitor for you if he feels that you need one. Take your blood pressure at the same time every day and write down your results. There is a handy blood pressure chart you can use for this. Take this chart with you when you visit your medical home. And be sure to bring in your blood pressure monitor so your PCP can check its accuracy.
There is no safe level of high blood pressure. High blood pressure does not go away after time, it is a life-long disease. Work with your PCP and follow your PCP’s advice to help keep your blood pressure under control.
Sources: Centers for Disease Control and Prevention, American Heart Association, Choosemyplate.gov
So, what is high blood pressure?
As your heart pumps blood, the blood pushes against the walls of blood vessels. This force is called blood pressure. The higher your blood pressure is, the more the blood pushes on the the blood vessels, and the harder your heart has to work to pump blood to all of your body.
How do you know if you have high blood pressure?
To find if you have high blood pressure, visit your Primary Care Provider (PCP) at your medical home for a check-up. This is very important because high blood pressure has no symptoms. That is why it is called the silent killer.
If your PCP at your medical home tells you that you have high blood pressure, there are many ways you can help control it.
Choosing a healthy diet low in salt is a great start. An easy way to eat healthy is to divide your plate into four equal parts. Two parts should be filled with fruits and vegetables, preferably raw or steamed. Fill one part with protein, such as chicken breast. The last part is your starch, like a piece of whole wheat bread or brown rice. Avoid fried foods and sugary sweets.
Exercise helps you strengthen your heart, feel better, and reduce stress. Your PCP can guide you on appropriate exercise routines.
If you smoke, try to quit. Everytime you smoke, your blood vessels constrict, causing your blood pressure to rise even higher. If you need help quitting, call the Illinois Tobacco Quitline at 1-866-Quit-Yes. The call is free.
If blood pressure medicine is prescribed by your doctor, be sure to take it as prescribed. Ask your PCP or pharmacist for help if the directions are not clear to you. Make a plan to help you remember to take your medicine every day. Use a calendar and check off when you have taken your pill.
If you miss your dose, contact your PCP for instructions on what to do. If your PCP prescribes more than one medicine, write these medicines down in a chart, and check them off as you take them.
The American Heart Association offers a free medicine chart to make this easy for you. Be sure to take this chart with you when you visit any medical or dental provider.
Your PCP may order a blood pressure monitor for you if he feels that you need one. Take your blood pressure at the same time every day and write down your results. There is a handy blood pressure chart you can use for this. Take this chart with you when you visit your medical home. And be sure to bring in your blood pressure monitor so your PCP can check its accuracy.
There is no safe level of high blood pressure. High blood pressure does not go away after time, it is a life-long disease. Work with your PCP and follow your PCP’s advice to help keep your blood pressure under control.
Sources: Centers for Disease Control and Prevention, American Heart Association, Choosemyplate.gov
Thursday, September 13, 2012
IHC Fall 2012 Provider Profiles are available online
The Illinois Health Connect Fall 2012 Provider Profiles have been posted to the IHC Provider Portal, which can be viewed using the MEDI System. Hard copies are being mailed to each IHC medical home.
Data in the IHC Provider Profiles is gathered from adjudicated claims from the Illinois Department of Healthcare and Family Services (HFS). Dates of service covered on the Fall 2012 Provider Profiles range from April 1, 2011 through March 31, 2012. This is not the same data used to calculate the 2011 or 2012 IHC Bonus Payment for High Performance.
The Provider Profiles are sent semi-annually to each IHC Primary Care Provider (PCP). The profiles are an overview of each PCP's performance in several clinical indicators and are issued to assist medical homes with quality assurance efforts.
IHC Quality Assurance Nurses (QAN) are available to meet with PCPs by appointment to discuss Provider Profiles and other IHC Quality Tools. Call your QAN or the IHC Provider Services Help Desk at 1-877-912-1999, extension 3, to schedule an appointment with a QAN.
The Provider Profiles are created with input from the Quality Management Subcommittee. Anyone interested in participating in this subcommittee should contact IHC Quality Assurance Manager Cari VonderHaar.
Data in the IHC Provider Profiles is gathered from adjudicated claims from the Illinois Department of Healthcare and Family Services (HFS). Dates of service covered on the Fall 2012 Provider Profiles range from April 1, 2011 through March 31, 2012. This is not the same data used to calculate the 2011 or 2012 IHC Bonus Payment for High Performance.
The Provider Profiles are sent semi-annually to each IHC Primary Care Provider (PCP). The profiles are an overview of each PCP's performance in several clinical indicators and are issued to assist medical homes with quality assurance efforts.
IHC Quality Assurance Nurses (QAN) are available to meet with PCPs by appointment to discuss Provider Profiles and other IHC Quality Tools. Call your QAN or the IHC Provider Services Help Desk at 1-877-912-1999, extension 3, to schedule an appointment with a QAN.
The Provider Profiles are created with input from the Quality Management Subcommittee. Anyone interested in participating in this subcommittee should contact IHC Quality Assurance Manager Cari VonderHaar.
Tuesday, September 11, 2012
HFS starting to enforce prior apporval policy for medications
The Illinois Department of Healthcare and Family Services (HFS) has started to review prescriptions for HFS clients in accordance with the prior approval policy for medications established by the Save Medicaid Access and Resources Together (SMART) Act. HFS started the review with clients who fill more than 10 prescriptions per month and will gradually expand the review.
HFS will allow clients to exceed four prescriptions per month in certain situations, with prior approval. HFS will review each request on a case-by-case basis. If approved, each prior approval request will be valid for one year.
Prior approval can be done via telephone (1-800-252-8942), fax (217-524-7264 or 217-524-0404) or a new application on the HFS MEDI System.
When a pharmacy bills for prescription that exceeds the limit, the claim will reject with some exceptions. The monthly limitation applies to name brand and generic drugs. Over-the-counter drugs and non-drug items such as blood glucose test strips are not subject to the limit.
The following classes of drugs are exempt from the limit: oncolytics, anti-retroviral agents, contraceptives, immunosuppressives and antibiotics. Compounds will count as one prescription. In an emergency situation, a pharmacy may dispense a 72-hour supply and HFS will pay for that 72-hour supply.
The prior approval form and and an online request application are posted on this HFS Pharmacy page. Providers can also check the status of their requests through and online application. HFS asks that providers do not call to check the status of requests.
HFS will allow clients to exceed four prescriptions per month in certain situations, with prior approval. HFS will review each request on a case-by-case basis. If approved, each prior approval request will be valid for one year.
Prior approval can be done via telephone (1-800-252-8942), fax (217-524-7264 or 217-524-0404) or a new application on the HFS MEDI System.
When a pharmacy bills for prescription that exceeds the limit, the claim will reject with some exceptions. The monthly limitation applies to name brand and generic drugs. Over-the-counter drugs and non-drug items such as blood glucose test strips are not subject to the limit.
The following classes of drugs are exempt from the limit: oncolytics, anti-retroviral agents, contraceptives, immunosuppressives and antibiotics. Compounds will count as one prescription. In an emergency situation, a pharmacy may dispense a 72-hour supply and HFS will pay for that 72-hour supply.
The prior approval form and and an online request application are posted on this HFS Pharmacy page. Providers can also check the status of their requests through and online application. HFS asks that providers do not call to check the status of requests.
Wednesday, September 5, 2012
Asking questions is the key to great health!
A great team of doctors, nurses and other healthcare staff can create a good medical home. The key to a great medical home is you! A great medical home is based on great communication.
As a patient, you can help get the best possible care by being an active member of your healthcare team. Being involved means being prepared and asking questions.
Before you go to the doctor:
1) Make a list of all your questions and concerns. That way you won’t forget to ask any important questions. Your Primary Care Provider (PCP) at your medical home may not be able to tackle all of your health concerns in one visit. Your PCP should be able to let you know how to make a follow-up appointment.
2) If you have seen any other doctors, such as specialists, had any tests or gone to the Emergency Room, bring all the names, dates, phone numbers and any reports with you to share with your PCP.
3) Make a list of all your medications including dosages. Or better yet, bring all of your pills with you (including those prescribed by other doctors). Your PCP can ensure that you are taking the right medicines and that there are no interactions.
During your visit:
1) Take notes during your visit. If you have a serious medical condition, bring a trusted relative or friend with you to help you listen and take notes.
2) Ask your PCP for any handouts about your medical conditions.
3) Ask your doctor if he/she can recommend some safe Web sites if you plan to do some research at home. A lot of medical information on the web is false so don’t think Google is going to answer all your questions. A good Web site for basic health information is http://www.familydoctor.org.
4) Ask your PCP questions like: What is my diagnosis? What are my treatment options? What are the benefits of each option? What are the side effects?
Will I need a test? What is the test for? What will the results tell me?
What will the medicine you are prescribing do? How do I take it? Are there any side effects?
After your visit:
If you have any remaining questions or your doctor was not able to address all of your medical concerns, make a follow-up appointment. If you are uncertain about how to take your medicines or get a recommended test, call your PCP. All Illinois Health Connect PCPs with must be available 24 hours per day.
Great health starts with a great medical home, and a great medical home starts with great communication. Asking questions until you thoroughly understand your health and your doctor’s recommendations is the key. Check out the AHRQ Web site for more information about doctor-patient communication.
As a patient, you can help get the best possible care by being an active member of your healthcare team. Being involved means being prepared and asking questions.
Before you go to the doctor:
1) Make a list of all your questions and concerns. That way you won’t forget to ask any important questions. Your Primary Care Provider (PCP) at your medical home may not be able to tackle all of your health concerns in one visit. Your PCP should be able to let you know how to make a follow-up appointment.
2) If you have seen any other doctors, such as specialists, had any tests or gone to the Emergency Room, bring all the names, dates, phone numbers and any reports with you to share with your PCP.
3) Make a list of all your medications including dosages. Or better yet, bring all of your pills with you (including those prescribed by other doctors). Your PCP can ensure that you are taking the right medicines and that there are no interactions.
During your visit:
1) Take notes during your visit. If you have a serious medical condition, bring a trusted relative or friend with you to help you listen and take notes.
2) Ask your PCP for any handouts about your medical conditions.
3) Ask your doctor if he/she can recommend some safe Web sites if you plan to do some research at home. A lot of medical information on the web is false so don’t think Google is going to answer all your questions. A good Web site for basic health information is http://www.familydoctor.org.
4) Ask your PCP questions like: What is my diagnosis? What are my treatment options? What are the benefits of each option? What are the side effects?
Will I need a test? What is the test for? What will the results tell me?
What will the medicine you are prescribing do? How do I take it? Are there any side effects?
After your visit:
If you have any remaining questions or your doctor was not able to address all of your medical concerns, make a follow-up appointment. If you are uncertain about how to take your medicines or get a recommended test, call your PCP. All Illinois Health Connect PCPs with must be available 24 hours per day.
Great health starts with a great medical home, and a great medical home starts with great communication. Asking questions until you thoroughly understand your health and your doctor’s recommendations is the key. Check out the AHRQ Web site for more information about doctor-patient communication.
Monday, September 3, 2012
Pregnant? Get off to a good start with these resources
It is best to get prenatal care as soon as you know you are pregnant and continue to get care throughout your pregnancy. You should use the same doctor or clinic for all your prenatal care. Take good care of yourself while you are pregnant. Take prenatal vitamins with folic acid. Exercise regularly. Don’t smoke, drink alcohol or use drugs.
It is also very important to continue to see your Primary Care Physician (PCP) at your medical home or your OB/GYN after the baby is born. You can talk to your PCP or OB/GYN about family planning and birth control.
WIC/Breastfeeding
Eating healthy foods is important when you are pregnant! WIC is a food assistance program for Women, Infants and Children. WIC helps pregnant women, new moms, babies and young children eat well and stay healthy.
Make sure you sign up for WIC while you are pregnant!
WIC can help you learn how to eat well for your growing baby. It is also important that babies and young children eat right. This helps them grow up healthy and strong. With WIC, you can get healthy foods. Foods available are whole grains, milk, eggs, cheese, fruits and vegetables, juice, cereal, dried beans or peas, baby foods, peanut butter and iron-fortified infant formula for babies who are not breastfed.
WIC helps women understand how to breastfeed. You can get answers to questions about breastfeeding, support and counseling. If you are pregnant or thinking about having a baby, make plans now to breastfeed your baby for the first year of life. Breastfeeding is the normal and natural way to feed your baby. Breast milk is all your baby needs for the first six months. You can keep your baby healthier by breastfeeding. Breast milk protects babies from ear infections, colds, allergies, diarrhea and constipation. Your baby will be sick less and have fewer doctor visits.
Breastfed children are less likely to have diabetes or become overweight in childhood. Breastfeeding saves money, because there are no formula or bottle costs. You may also have fewer doctor bills and medication costs.
Breastfeeding helps you bond with your baby. Holding your baby while you nurse makes your baby feel loved and close to you. Breastfeeding has health benefits for moms, too. Breastfeeding lowers the risk of ovarian cancer, breast cancer and osteoporosis.
To see if you qualify for WIC, visit a WIC Clinic. To locate a WIC office near you, call 1-800-323-4769 (TTY: 1-866-295-6817) or go online at http://www.dhs.state.il.us and click on “Food”.
Family Case Management
Family Case Management (FCM) is an Illinois Department of Human Services (DHS) program that helps pregnant women, infants and children get needed services. Help with healthcare and transportation is available. FCM can provide education on issues such as pregnancy, childbirth, parenting, family planning and birth control. For more information, visit your local DHS office. Or call 1-800-843-6154 (TTY: 1-800-447-6404) or go online at http://www.dhs.state.il.us.
text4baby
To help you during your pregnancy with information about caring for your health and giving your baby the best possible start in life, check out text4baby. Text4baby is free. It provides important health information and resources in simple text messages.
Registration is easy and can be done from your cell phone. Just text “Baby” (or “Bebe” for Spanish) to 511411. You’ll be asked to enter your baby’s due date or your baby’s birthday, and your zip code. Once registered, you will receive three text messages a week, until your baby is a year old, with tips for your pregnancy or caring for your baby.
Quit Smoking
Quitting smoking will improve your chances of having a healthy baby. During pregnancy, moms who quit smoking are proud of themselves for breaking the addiction. By quitting, former smokers get many health benefits. They cut down on their risk of having lung disease, a heart attack or getting cancer.
The people who you live with, especially your children, will also be healthier. You will have extra money to spend on other important things for your family. Quitting smoking is one of the most important things you will ever do.
However, it is not easy. For help and support, contact a medical professional at the Illinois Tobacco Quitline. The Quitline is open seven days a week from 7 a.m. to 11 p.m. The number is 1-866-Quit-Yes (TTY: 1-800-501-1068). This call is free.
Post Partum Depression
Pay attention to your feelings during and after pregnancy. Do you feel sad nearly all the time? Have you stopped feeling pleasure or worry too much? Have you lost interest in food? Talk to your PCP right away.
If you need help finding a PCP, Illinois Health Connect can locate a medical home for you while you are pregnant and after you have the baby. Call IHC between 8 a.m. and 7 p.m., Monday through Friday. The number is 1-877-912-1999 (TTY: 1-866-565-8577). The call is free.
Sources: Illinois Department of Human Services, text4baby.org, Illinois Department of Public Health
It is also very important to continue to see your Primary Care Physician (PCP) at your medical home or your OB/GYN after the baby is born. You can talk to your PCP or OB/GYN about family planning and birth control.
WIC/Breastfeeding
Eating healthy foods is important when you are pregnant! WIC is a food assistance program for Women, Infants and Children. WIC helps pregnant women, new moms, babies and young children eat well and stay healthy.
Make sure you sign up for WIC while you are pregnant!
WIC can help you learn how to eat well for your growing baby. It is also important that babies and young children eat right. This helps them grow up healthy and strong. With WIC, you can get healthy foods. Foods available are whole grains, milk, eggs, cheese, fruits and vegetables, juice, cereal, dried beans or peas, baby foods, peanut butter and iron-fortified infant formula for babies who are not breastfed.
WIC helps women understand how to breastfeed. You can get answers to questions about breastfeeding, support and counseling. If you are pregnant or thinking about having a baby, make plans now to breastfeed your baby for the first year of life. Breastfeeding is the normal and natural way to feed your baby. Breast milk is all your baby needs for the first six months. You can keep your baby healthier by breastfeeding. Breast milk protects babies from ear infections, colds, allergies, diarrhea and constipation. Your baby will be sick less and have fewer doctor visits.
Breastfed children are less likely to have diabetes or become overweight in childhood. Breastfeeding saves money, because there are no formula or bottle costs. You may also have fewer doctor bills and medication costs.
Breastfeeding helps you bond with your baby. Holding your baby while you nurse makes your baby feel loved and close to you. Breastfeeding has health benefits for moms, too. Breastfeeding lowers the risk of ovarian cancer, breast cancer and osteoporosis.
To see if you qualify for WIC, visit a WIC Clinic. To locate a WIC office near you, call 1-800-323-4769 (TTY: 1-866-295-6817) or go online at http://www.dhs.state.il.us and click on “Food”.
Family Case Management
Family Case Management (FCM) is an Illinois Department of Human Services (DHS) program that helps pregnant women, infants and children get needed services. Help with healthcare and transportation is available. FCM can provide education on issues such as pregnancy, childbirth, parenting, family planning and birth control. For more information, visit your local DHS office. Or call 1-800-843-6154 (TTY: 1-800-447-6404) or go online at http://www.dhs.state.il.us.
text4baby
To help you during your pregnancy with information about caring for your health and giving your baby the best possible start in life, check out text4baby. Text4baby is free. It provides important health information and resources in simple text messages.
Registration is easy and can be done from your cell phone. Just text “Baby” (or “Bebe” for Spanish) to 511411. You’ll be asked to enter your baby’s due date or your baby’s birthday, and your zip code. Once registered, you will receive three text messages a week, until your baby is a year old, with tips for your pregnancy or caring for your baby.
Quit Smoking
Quitting smoking will improve your chances of having a healthy baby. During pregnancy, moms who quit smoking are proud of themselves for breaking the addiction. By quitting, former smokers get many health benefits. They cut down on their risk of having lung disease, a heart attack or getting cancer.
The people who you live with, especially your children, will also be healthier. You will have extra money to spend on other important things for your family. Quitting smoking is one of the most important things you will ever do.
However, it is not easy. For help and support, contact a medical professional at the Illinois Tobacco Quitline. The Quitline is open seven days a week from 7 a.m. to 11 p.m. The number is 1-866-Quit-Yes (TTY: 1-800-501-1068). This call is free.
Post Partum Depression
Pay attention to your feelings during and after pregnancy. Do you feel sad nearly all the time? Have you stopped feeling pleasure or worry too much? Have you lost interest in food? Talk to your PCP right away.
If you need help finding a PCP, Illinois Health Connect can locate a medical home for you while you are pregnant and after you have the baby. Call IHC between 8 a.m. and 7 p.m., Monday through Friday. The number is 1-877-912-1999 (TTY: 1-866-565-8577). The call is free.
Sources: Illinois Department of Human Services, text4baby.org, Illinois Department of Public Health
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