The Illinois Department of Healthcare and Family Services (HFS) issued a Provider Release to update providers about the implementation of the prior approval policy for medications.
The purpose of this policy is to have providers review their patients' entire profile of maintenance medications, and where possible and clinically appropriate, reduce duplication, eliminate unnecessary medications and poly-pharmacy, and avoid other problems. Antibiotics, immunosuppressives, oncology agents, anti-retroviral agents and contraceptives are excluded from needing prior approval. PA is required for name brand and generic drugs.
This statutory requirement was signed into law on June 30 as part of the SMART Act legislation and will eventually apply to all adults and children who have coverage through HFS medical programs.
The implementation of the policy is being phased in gradually as HFS determines its capacity to process the Prior Approval (PA) requests.
At this time, HFS clients less than 19 years old will not be affected. Until further notice from HFS, PA requests are not necessary for All Kids clients. HFS is currently requiring prior approval requests for adult clients who fill more than nine prescriptions in the previous 30-day period.
Pharmacies are able to dispense a 72-hour supply of medications in an emergency situation when HFS is closed and not able to process PA requests.
PA requests will generally be granted for a period of one year.
Providers are highly encouraged to use the new Drug Prior Approval/Refill Too Soon application on the MEDI System to submit PA requests. While PA requests can be submitted through fax or phone, these requests require HFS to do data entry which is adding an average of four hours to the review process.
Providers can check the status of a PA request using MEDI if the request was submitted via MEDI. If the PA request was sent via fax or phone, providers are encouraged to use the HFS online status inquiry system. Providers should not call the HFS Pharmacy Hotline to check on the status of a PA request.
If you need assistance with MEDI registration, please contact your IHC Provider Services Representative or the IHC Provider Services Help Desk at 877-912-1999, extension 3. A step-by-step guide to MEDI registration is available on the IHC Web site.
The HFS Pharmacy page contains the PA request form, a link to the online status inquiry system as well as the phone and fax numbers for HFS Pharmacy.
IHC also posted information on the Bulletin Board about this policy on October 11, September 25 and September 11. Check back to the Bulletin Board for more updates on this policy is implemented.
Wednesday, October 31, 2012
Saturday, October 27, 2012
IHC attends APN Midwest Conference for first time
Illinois Health Connect Provider Services Recruiter Sonya Harper attended the Illinois Society for Advanced Practice Nursing (ISAPN) 2012 APN Midwest Conference in Lombard on October 25 and October 26.
This was the first year IHC has attended this conference, staffing a booth in the exhibit hall to educate attendees about the IHC program. The topics addressed at the conference during the days IHC attended included: current legislation, policy and politics; diabetes care; atrial fibulation management; sexual transmitted infections from acute to primary care; pharmacology; trauma resuscitation.
This was the first year IHC has attended this conference, staffing a booth in the exhibit hall to educate attendees about the IHC program. The topics addressed at the conference during the days IHC attended included: current legislation, policy and politics; diabetes care; atrial fibulation management; sexual transmitted infections from acute to primary care; pharmacology; trauma resuscitation.
Friday, October 26, 2012
IHC exhibits at Illinois Statewide Transition Conference
Illinois Health Connect Provider Services Trainer Danielle Parrillo and IHC Enrollee Services team members Lynn Kramer and Glenn Nye staffed a table in the exhibit hall of the 8th Annual Illinois Statewide Transition Conference in St. Charles on October 25 and October 26. It was the second consecutive year IHC has attended this conference to educate attendees about the IHC program.
The goals of the conference were to promote effective, person-centered transition planning to address all aspects of adult life for youth with disabilities. Practical and evidenced-based strategies were presented in relation to family involvement, student self-determination, inter-agency collaboration and effective program structures.
IHC staff members interacted with a variety of attendees, including high school students, young adults with disabilities, family members of youth with disabilities, teachers, vocational professionals, caregivers, healthcare professionals, community advocates and college students pursuing careers in special education.
The goals of the conference were to promote effective, person-centered transition planning to address all aspects of adult life for youth with disabilities. Practical and evidenced-based strategies were presented in relation to family involvement, student self-determination, inter-agency collaboration and effective program structures.
IHC staff members interacted with a variety of attendees, including high school students, young adults with disabilities, family members of youth with disabilities, teachers, vocational professionals, caregivers, healthcare professionals, community advocates and college students pursuing careers in special education.
Wednesday, October 24, 2012
NAMI Illinois Conference offers chance to explain IHC
Illinois Health Connect attended the NAMI Illinois 2012 Conference on October 19-20 in Lisle, sponsoring a table as an exhibitor for the first time at this conference.
IHC Communications Specialist Sean Fuchs and IHC Provider Services Trainer Danielle Parrillo met with mental health professionals, advocates and NAMI members and other attendees at the conference, answering questions about the IHC primary care case management program and how IHC can assist clients with accessing mental health services.
IHC Communications Specialist Sean Fuchs and IHC Provider Services Trainer Danielle Parrillo met with mental health professionals, advocates and NAMI members and other attendees at the conference, answering questions about the IHC primary care case management program and how IHC can assist clients with accessing mental health services.
IDPH has mailed educational materials about lead screening
The Illinois Department of Public Health (IDPH) has recently mailed provider education materials about lead poisoning to Medicaid providers who serve young children. These mailings are dated October 10, 2012 and include a cover letter from IDPH, a poster and information about the Illinois Health Connect Bonus Payment for High Performance, which has a bonus measure for lead screening.
As Illinois has the highest incidence of lead poisoning of children in the nation, IDPH wants to remind providers that federal mandates and Illinois Department of Healthcare and Family Services (HFS) policy recommend that all children who receive All Kids benefits from HFS be considered at risk for lead poisoning. Children should be screened prior to 12 months of age and again prior to 24 months. All children enrolled in HFS medical programs are expected to be screened for lead poisoning regardless of where they live.
The 2012 IHC bonus measure for lead screening has a benchmark of 72.2 percent of children who have had at least one capillary or venous lead screening prior to age 24 months.
For more information, education materials about lead screening or to schedule an in-service training, contact IDPH at 217-782-3517. For specific questions about IHC bonus measure, contact an IHC Quality Assurance Nurse or the IHC Provider Services Help Desk at 877-912-1999, extension 3.
As Illinois has the highest incidence of lead poisoning of children in the nation, IDPH wants to remind providers that federal mandates and Illinois Department of Healthcare and Family Services (HFS) policy recommend that all children who receive All Kids benefits from HFS be considered at risk for lead poisoning. Children should be screened prior to 12 months of age and again prior to 24 months. All children enrolled in HFS medical programs are expected to be screened for lead poisoning regardless of where they live.
The 2012 IHC bonus measure for lead screening has a benchmark of 72.2 percent of children who have had at least one capillary or venous lead screening prior to age 24 months.
For more information, education materials about lead screening or to schedule an in-service training, contact IDPH at 217-782-3517. For specific questions about IHC bonus measure, contact an IHC Quality Assurance Nurse or the IHC Provider Services Help Desk at 877-912-1999, extension 3.
Thursday, October 11, 2012
HFS Q&A: Drug Prior Approval policy, part two
In an effort to fully explain the SMART Act mandated prior approval policy for medications, the Illinois Department of Healthcare and Family Services (HFS) has provided the following answers to questions that providers recently asked of Illinois Health Connect. The answers in this post were sent to IHC on October 10. HFS answered a previous set of questions in a IHC Bulletin Board post on September 25.
Q: Has HFS started to enforce the limit of four prescriptions per month?
HFS: The Department is currently rejecting prescriptions billed for patients who exceed eight (8) prescriptions in a 30-day period. Once a script rejects and after reviewing a patient's profile to reduce duplication and unnecessary medications where clinically appropriate, the prescriber should request Prior Approval for any medication contained on the approvable drug list that the patient needs. 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.
Q: How can a provider determine if an additional provider is prescribing drugs for a patient?
HFS: Prescribers can access a patient's Claims History on the IHC Provider Portal via the HFS MEDI System to identify all prescriptions being filled by the patient that are being reimbursed by the HFS Medicaid program.
Q: Does HFS have a schedule for Prior Approval to drop from 10-8-6-4 on specific dates?
HFS: The Department is currently rejecting prescriptions billed for patients that exceed eight (8) prescriptions in a 30 day period. The Department is working toward the four per month limit over time to assess its capability of handling the Prior Approval requests and to respond to situations that arise, which could not have been anticipated prior to implementation.
Q: When a Prior Approval request is submitted via phone or fax, is there a approval confirmation sent to provider by fax or phone?
HFS: No.
Q: How are providers notified when Prior Approval requests are approved?
HFS: The HFS pharmacist reviewing the PA request may contact the prescriber to request additional information necessary to make the determination, but prescribers are not specifically notified of whether or not a request has been approved. The provider can determine approval status using MEDI or the Pharmacy Prior Approval Hotline at 1-800-252-8942. If PA is denied, a denial letter is sent to the patient.
Q: Are PA requests processed at different speeds when submitted by phone, fax or MEDI?
HFS: There is no significant variance in processing time based on how PA request was received. PA requests are reviewed in the order they are received unless the reviewing pharmacist is waiting on additional information from prescriber or pharmacy.
Q: Where can a provider get further information that is not detailed in the HFS Provider Release or the Four Prescription Limit page on HFS Web site?
HFS: Providers should call the HFS Bureau of Pharmacy Services at 877-782-5565, extension 7.
Q: Has HFS started to enforce the limit of four prescriptions per month?
HFS: The Department is currently rejecting prescriptions billed for patients who exceed eight (8) prescriptions in a 30-day period. Once a script rejects and after reviewing a patient's profile to reduce duplication and unnecessary medications where clinically appropriate, the prescriber should request Prior Approval for any medication contained on the approvable drug list that the patient needs. 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.
Q: How can a provider determine if an additional provider is prescribing drugs for a patient?
HFS: Prescribers can access a patient's Claims History on the IHC Provider Portal via the HFS MEDI System to identify all prescriptions being filled by the patient that are being reimbursed by the HFS Medicaid program.
Q: Does HFS have a schedule for Prior Approval to drop from 10-8-6-4 on specific dates?
HFS: The Department is currently rejecting prescriptions billed for patients that exceed eight (8) prescriptions in a 30 day period. The Department is working toward the four per month limit over time to assess its capability of handling the Prior Approval requests and to respond to situations that arise, which could not have been anticipated prior to implementation.
Q: When a Prior Approval request is submitted via phone or fax, is there a approval confirmation sent to provider by fax or phone?
HFS: No.
Q: How are providers notified when Prior Approval requests are approved?
HFS: The HFS pharmacist reviewing the PA request may contact the prescriber to request additional information necessary to make the determination, but prescribers are not specifically notified of whether or not a request has been approved. The provider can determine approval status using MEDI or the Pharmacy Prior Approval Hotline at 1-800-252-8942. If PA is denied, a denial letter is sent to the patient.
Q: Are PA requests processed at different speeds when submitted by phone, fax or MEDI?
HFS: There is no significant variance in processing time based on how PA request was received. PA requests are reviewed in the order they are received unless the reviewing pharmacist is waiting on additional information from prescriber or pharmacy.
Q: Where can a provider get further information that is not detailed in the HFS Provider Release or the Four Prescription Limit page on HFS Web site?
HFS: Providers should call the HFS Bureau of Pharmacy Services at 877-782-5565, extension 7.
Wednesday, October 10, 2012
Breast Cancer Awareness: Get a screening mammogram
Mammograms are an important service for women. Women should get screenings every two years beginning at age 40. Getting a mammogram can lead to the early detection of breast cancer, which is the most common cancer for women.
October is Breast Cancer Awareness Month. Ask your PCP about scheduling a mammogram appointment today.
Mammograms are a covered service with your HFS medical card. Illinois Health Connect can help you schedule an appointment.
A mammogram is a low-dose X-ray. This X-ray shows the inside of your breast. Mammograms can find cancer up to two years before lumps can be felt. Finding the cancer early is important. Early detection provides women with better treatment options and results.
An average mammogram appointment takes roughly 20 minutes. Your breast will be placed on a shelf between two smooth, plastic plates. The breast needs to be spread flat for the X-ray to work properly. You will feel pressure, which can be somewhat uncomfortable.
Two or more X-rays will be taken of each breast. The doctor who reads your mammogram will compare the X-rays to your previous mammograms.
October is Breast Cancer Awareness Month. Ask your PCP about scheduling a mammogram appointment today.
Mammograms are a covered service with your HFS medical card. Illinois Health Connect can help you schedule an appointment.
A mammogram is a low-dose X-ray. This X-ray shows the inside of your breast. Mammograms can find cancer up to two years before lumps can be felt. Finding the cancer early is important. Early detection provides women with better treatment options and results.
An average mammogram appointment takes roughly 20 minutes. Your breast will be placed on a shelf between two smooth, plastic plates. The breast needs to be spread flat for the X-ray to work properly. You will feel pressure, which can be somewhat uncomfortable.
Two or more X-rays will be taken of each breast. The doctor who reads your mammogram will compare the X-rays to your previous mammograms.
Thursday, October 4, 2012
New VFC eligibility rules announced for 2013
The Illinois Department of Public Health (IDPH) has announced that due to budgetary concerns, the eligible population for the Vaccines For Children (VFC) Program will restricted effective January 1, 2013.
Underinsured children will no longer be allowed to get VFC immunizations at a private provider office. These children will need to get VFC immunizations from a Federally Qualified Health Center (FQHC), a Rural Health Center (RHC) or a local health department.
An underinsured client is a child who has commercial (private) insurance, but the insurance plan does not cover immunizations; a child whose insurance plan only covers certain immunizations (VFC eligible only for non-covered immunizations); or, a child whose insurance caps vaccine coverage at a certain amount.
These children have been VFC eligible through the VFC Plus Program. However, funds are not sufficient to support the Plus Program. This change is effective statewide and includes providers who participate in the VFC Chicago Program.
Children with All Kids coverage from Illinois Department of Healthcare and Family Services (HFS), the un-insured (self pay) and Native Americans will continue to be eligible to receive all VFC immunizations at private provider offices.
Underinsured children will no longer be allowed to get VFC immunizations at a private provider office. These children will need to get VFC immunizations from a Federally Qualified Health Center (FQHC), a Rural Health Center (RHC) or a local health department.
An underinsured client is a child who has commercial (private) insurance, but the insurance plan does not cover immunizations; a child whose insurance plan only covers certain immunizations (VFC eligible only for non-covered immunizations); or, a child whose insurance caps vaccine coverage at a certain amount.
These children have been VFC eligible through the VFC Plus Program. However, funds are not sufficient to support the Plus Program. This change is effective statewide and includes providers who participate in the VFC Chicago Program.
Children with All Kids coverage from Illinois Department of Healthcare and Family Services (HFS), the un-insured (self pay) and Native Americans will continue to be eligible to receive all VFC immunizations at private provider offices.
Wednesday, October 3, 2012
Adults do not have co-payment for preventive visits
The Illinois Department of Healthcare and Family Services (HFS) Bureau of Comprehensive Health Services issued a clarification to Illinois Health Connect on October 1 stating that there are no co-payments for preventive visits for HFS clients of any age, regardless of their eligibility type.
This means that adults do not have a co-payment for preventive visits, including annual well visits.
An Illinois Health Connect memo titled "HFS Cost Sharing Provider Release" issued in August incorrectly stated that "co-payments will apply for adult preventive visits, including annual well visits." A revised memo will be posted to the IHC Provider Notices page.
This means that adults do not have a co-payment for preventive visits, including annual well visits.
An Illinois Health Connect memo titled "HFS Cost Sharing Provider Release" issued in August incorrectly stated that "co-payments will apply for adult preventive visits, including annual well visits." A revised memo will be posted to the IHC Provider Notices page.
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