KP Online-Affiliate is Here for You T
Transcript of KP Online-Affiliate is Here for You T
A publ icat ion for the Kaiser Permanente of Georg ia a ff i l ia ted communi ty network
Network NewsFALL 2008
KP Online-Affiliate is Here for YouT
hanks go out to all of you for your support in
our roll-out of KP Online-Affiliate.
Since this initiative is still in its early stages, we
want to take this opportunity to focus on referrals,
since they are an integral part of the KP Online-
Affiliate program. Below are some key points to
help you answer some frequently asked questions.
What You Need to Know About KP Online-Affiliate Claims and Specialty Referrals
For HMO Plan Members:
• HMO members have always had to have
referrals to see specialty providers.
• A referral in KP Online-Affiliate is required for
payment of all specialty office visits.
• Referrals are not required for Ob/Gyn, dermatology,
ophthalmology, optometry and behavioral health
providers.
• Kaiser Permanente has new referral guidelines:
Specialty referrals are now good for 270 days
(nine months) and default to six visits.
For Multi-Choice Plan Members:
• Multi-Choice members do not require a referral.
You do not need to generate referrals in
KP Online-Affiliate.
• Primary care physicians are encouraged to provide
guidance when members need specialty care. Their
out-of-pocket costs will be lower with Tier 1 specialists.
• Authorizations are required for procedures and
services on the Targeted Review List. These should
be requested via KP Online-Affiliate.
For Specialty-to-Specialty Referrals (HMO
Members):
• Members needing specialty care should be
referred by their primary care physician to the
appropriate specialist.
• In the coming months, we will be instituting a
new policy limiting specialty-to-specialty referrals.
We will contact you directly with clarifying details.
How Can Members Get Help With TheirReferrals?
• Members and physicians that need to request a
new referral or update ongoing referrals will need
to contact the member’s primary care physician.
• Primary care physicians can assist members in
updating specialty office visit referrals by entering
a referral into KP Online-Affiliate.
Questions about KP Online-Affiliate? We’ve got answers!Call the KP Online-Affiliate Telephone Help Line @ 1-877-240-1433
>> learn more on page 3
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Network News - Fall 2008 2
Clinical Guidelines Coming On-lineK
aiser Permanente updates each clinical guideline every
two years. These updates will be posted on KP Online-
Affiliate soon. We will be highlighting the most recent changes,
made quarterly, in hopes that you will review these to support
your practice.
The most recent updates will include those for ADHD, Chronic
Kidney Disease, Diabetes, Depression and the Pediatric
Immunization Schedule. Also, new to the national guidelines
are three clinical practice resources: Chronic Pain (long term
opoid therapy for adults), Chronic Pain (screening and
assessment) and Urology (standardizes hematuria evaluation).
To request a copy, please contact Kristen Berger by calling
404-364-4885.
Supporting Network Providers with the SMART® Registry
T
he SMART® Registry, a
Healthy Solutions tool to
help physicians better manage
chronic patients, was distrib-
uted in September 2008.
The Registry provides data
about patient demographics,
diagnoses and utilization; and
information on whether gaps
exist in recommended evi-
dence-based clinical care.
Chronic conditions identified
include diabetes, coronary
heart disease, heart failure,
asthma, chronic obstructive
pulmonary disease and co-
morbid hypertension. The
Registry identifies whether or
not patients are currently in
contact with a Healthy
Solutions Health Coach.
New to the Registry are med-
ication persistence rates,
which provide the percentage
of usage for dispensed med-
ications, specifically
ACEI/ARBs, lipid lowering
agents and beta blockers.
Physicians can use the
Registry to refer appropriate
patients to Healthy Solutions,
Kaiser Permanente’s health
coaching service.
For more information about
Healthy Solutions and the
SMART® Registry, please
contact Kristen Berger at
404-364-4885.
K
aiser Permanente’s Total Health Assessment
(THA) is a dynamic tool that includes a health
risk assessment (HRA); a completely confidential,
online survey designed to help members understand
the relationship between their behaviors and their
health. THA also links members to our free Healthy
Lifestyle tools.
Another valuable aspect of our THA is that Kaiser
Permanente members can choose to have their
HRA results integrated into their KP HealthConnect
electronic medical record and shared with their
primary care physician.
Make sure to let your patients who are Kaiser
Permanente members know about THA. They can
access THA by visiting www.kp.org and clicking on
the “My Health Manager” section.
It’s that easy!
Better Health is a Click Away!
K
aiser Permanente has a
closed formulary.
Providers should adhere to
the Kaiser Permanente
formulary.
The formulary can be accessed by
visiting the Provider Web site at
http://providers.kp.org/ga.
The non-formulary exception process is
explained in depth in your Provider
Manual, found online.
Kaiser PermanenteDrug Formulary
A
ll Kaiser Permanente medical
records departments are cen-
tralized in one convenient loca-
tion. You should send consultation
reports to the fax numbers listed
at the end of this article. Please
continue to use the specific fax
number given to you if your office
or facility was contacted directly.
When consultation reports are
received, they will be scanned
into the patients’ electronic med-
ical record (EMR). Please include
the member’s name, date of birth
and medical record number
(MRN) on all correspondence
sent to Health Information
Management Systems (HIMS).
The physicians in your office have
view-only access to members’
EMR via KP Online-Affiliate,
which contains medical record
information from visits to Kaiser
Permanente medical offices, as
well as consultation reports sent
to our HIMS department.
Network News - Fall 2008 3
O
n September 1, Kaiser Permanente launched
our self-funding program. You may have
already seen the new member ID cards (they are
green) carried by these members.
In addition, a link to the self-funded program Web
site is now live on the home page of the provider
Web site. You should go here first to check
eligibility and benefits for self-funded members and
view claim information for self-funded members.
You may also call 1-866-800-1486.
If you are unsure whether a member is self-fund-
ed, this can be determined in KP Online-Affiliate by
clicking on “Demographics/Eligibility” and then
“Benefits” to display the member’s plan.
Please send self-funded claims to the following
address:
PLEASE NOTE: Do not send claims for Kaiser Permanente
members that are not self-funded to this
address. Your claims will be returned if you
do so.
Self-Funding Program Update
Claims Information Now Available on KP Online-AffiliateC
laims information is now available in KP Online-
Affiliate. To access this feature, click on the
“Claims” tab on the left side toolbar. Only claims
received since August 15, 2008, will be viewable
through this system.
To search for claims for a particular physician, select
a date range, select the provider’s name from the
drop down box and click “Search by Provider.”
To search for claims for the entire group, select a
date range and click “Search by Vendor.” A list of
claims will display. You can view details by clicking
on the claim ID.
In order to search for claims pertaining to a specific
member, select that member using “Patient Search”
and then click on the “Claims” tab on the left side
toolbar.
You can always refine a search by selecting a specif-
ic date range and either search by provider, vendor
or member. Once the search is complete, to view
details on a specific claim, click on the claim ID. A
detailed report will display.
In the coming months, the Claims detail view will
change to provide additional information in an easier
to read format.
We hope you enjoy these additional features on KP
Online-Affiliate!
>> continued from page 1
KPIC, Self-Funded Plan Administrator
P.O. Box 30547
Salt Lake City, UT 84130-0547
EDI: Payor ID 94320
Centralized Address for Kaiser Permanente Medical RecordsSpecialty Fax Numbers:
Behavioral Health 1-866-480-8082
Cardiology 1-866-401-2508
Home Health/SNF 1-866-402-4315
Hospitals 1-866-401-2503
Nephrology 1-866-840-5816
Opthamology 1-866-840-5811
Orthopedics 1-866-840-5812
Radiology 1-866-401-2502
Urology 1-866-840-5815
Don’t see your specialty above?
Fax your documents to
1-866-840-5818 or call us at
770-496-3686.
T
he newly-introduced Cardiovascular Disease
(CVD) Management Program gives Kaiser
Permanente members with diabetes and certain
cardiovascular-related diseases: an interdisciplinary
team of clinicians to help members live with and
manage their chronic conditions.
Launched this summer, the program is available for
members meeting specific criteria relating to cardio-
vascular conditions and Type 2 diabetes (see crite-
ria below). It pairs qualifying participants with a
team of nurse practitioners, clinical pharmacists and
licensed practical nurses who work with members
to help them best manage their conditions.
Teams are based out of each of Kaiser
Permanente’s 15 medical centers in metro Atlanta
and offer a variety of appointment types, ranging
from one-on-one visits to group sessions. Team
members work closely with a member’s primary
care physician (PCP), updating on the member’s
progress.
In addition, team members help program partici-
pants navigate Kaiser Permanente’s existing
resources designed specifically for
diabetes and cardiac conditions.
This program replaces the Pharmacy
Cardiac Risk Service (PCRS) and
aspects of the previous Diabetes
Program. All of the diabetes classes
and access to nutritional services are
still available.
All Kaiser Permanente members
meeting the program’s specific
criteria will be contacted about this
program. There is no need for you
to refer patients into this program.
We look forward to working with our
contracted PCPs through the new
CVD Management Program!
Network News - Fall 2008 4
KP Introduces CVD Management Program
CVD Management Program Criteria
Members with Diabetes
• Newly diagnosed with diabetes (within 6 months), OR
• A1c between 7.0-9.0% on 2 or more medications and/or
including insulin, OR
• LDL>99 mg/dL and <130 mg/dL
Members with Coronary Artery Disease
(without diabetes)
• LDL>99 mg/dL
Members with Heart Failure
(not included in above diabetes & CAD criteria)
• Heart failure with a risk score between 5 and 10 on
Impact Pro
Standards for Medical Record DocumentationK
aiser Permanente’s NCQA sur-
vey is scheduled for 2010. To
continue our efforts for survey readi-
ness, we are introducing a more
defined medical record documenta-
tion review process.
This process is a result of several
months of diligent work, and the
2006-2007 medical record docu-
mentation audits, which revealed
many opportunities for improvement.
In order to meet standards (CMS,
NCQA and Kaiser Permanente),
our goal is to achieve 90 percent or
better in medical records documen-
tation review.
An updated copy of the medical
records standards will soon be avail-
able online via KP Online-Affiliate.
You may also contact Evon Smith,
RN, at 404-364-7387 to request a
copy.
Also, see your provider manual for
information regarding our policies
on the confidentiality, availability
and organization of members’
medical records.
Diagnosis Coding: Hierarchical Condition CategoriesY
ou should code chronic systemic illnesses at
every patient visit and revise the diagnoses as
often as necessary. Maximizing face-to-face encoun-
ters throughout the year will ensure that the medical
record is a true reflection of your patient’s clinical
picture.
When submitting claims or requesting referrals
via KP Online-Affiliate, you should include the
following:
• Accurate diagnosis code(s) should be included
on all referral requests
• Report all diagnoses during the visit when
submitting claims
• Old MI should be coded in addition to CAD if
there is a history of an acute MI
• The medical cause of the fracture should
be identified (osteoporosis, metastatic, etc.)
• History of cancer codes should be used if there
is no active treatment (including radiation,
chemotherapy, surgery)
• Diabetes diagnosis should be as specific as
possible: i.e., Type 1 or Type 2, Controlled or
Uncontrolled. Manifestations should also be
documented—renal, vascular, neurologic, etc.,
and supported with data in the note, labs,
procedures or symptoms.
I
n an effort to adhere to state and federal
regulatory guidelines, Kaiser Permanente has
standardized our method for reviewing
billing practices.
We perform audits on claims data to detect and
categorize potentially anomalous billing patterns.
You may be contacted so that we can perform a
medical records review.
The review process is intended to ensure that
medical record documentation is adequate and
code assignments (e.g. ICD-9, CPT and
HCPCS) are appended accurately according
to both federal and state regulations.
As we move forward with the medical record
review process, we ask that you and your staff
cooperate with any requests for medical record
documentation.
We at Kaiser Permanente rely on our partnership
with you to provide quality health care to our
members. We will continue working with you to
make sure we are serving our members and
community to the best of our ability. If you have
any questions, please e-mail Tyrone Whitted at
Review of Billing Practices
Diagnosis Coding Required on Radiologyand Lab OrdersEffective immediately, you are now required
to submit diagnosis code(s) when submitting
orders for radiology and lab services
performed at Kaiser Permanente medical
offices.
Reminder: Timely Filing LimitKaiser Permanente has a standard timely filing
limit of 90 days from the date of service. Claims
submitted after this limit will be denied. Per the
terms of your contract, you are not permitted to
seek reimbursement from members for charges
denied due to untimely filing.
NDC Coding ClarificationProviders filing claims on UB-04 claim forms do
not need to include NDC coding to accompany
specific drug-related HCPCS codes for drugs.
Our article in the Spring Network News still
applies to all other providers filing CMS - 1500
claims forms.
Corrected ClaimsYou can now submit corrected claims via EDI.
You must indicate the claim has been
corrected or it may be denied as a duplicate
claim. Contact your EDI vendor or our Claims
department for detailed instructions on
submitting corrected claims.
Network News - Fall 2008 5
Network News - Fall 2008 6
Persistence of Beta-blocker Treatment after a Heart AttackP
atients treated for acute
myocardial infarction (AMI)
usually receive care from multi-
ple physicians during their hospi-
tal stay. During the post-hospital
visit, it is the primary care physi-
cian’s (PCP) role to coordinate
ongoing care for these patients.
One important component to
address during this visit is the
benefits and the need for long
term beta-blocker use. These
benefits are well-established and
patient understanding can help
to improve medication compli-
ance.
To assist PCPs in providing evi-
dence-based quality care to their
patients following AMI, we will
send a letter to PCPs when their
patient(s) have been discharged
with a diagnosis of AMI. We
request that you consider—if not
already done at discharge—
initiating long-term beta-blocker
management. If there is a history
of a contraindication or intoler-
ance to a beta-blocker that pre-
vents initiation, please document
this in your chart.
Persistence of beta-blocker
treatment after a heart attack is
one of the HEDIS (Healthcare
Effectiveness Data and
Information Set) quality metrics
used by NCQA (National
Committee for Quality
Assurance) to measure and
rank the quality of medical care
provided by health plans. It is
also used by health plans to
measure and rank the quality of
care provided by physicians to
their patients.
Your continued support in
providing quality care to our
Kaiser Permanente members
is appreciated. Please contact
George Kawamura, MD, assis-
tant to the Chief of Ambulatory
Medicine, if you have any
questions or require additional
information. Dr. Kawamura can
be reached by calling 770-931-
6147 or sending an e-mail to
RSV Therapy Available at Kaiser PermanenteR
espiratory Syncytial Virus (RSV)—the
leading cause of serious lower-respiratory
tract infection in children—season in Georgia
starts in November and ends in late March.
Kaiser Permanente offers RSV prophylaxis
with palivizumab (Synagis) during the peak RSV
season for infants and children who are at
high-risk of serious complications from RSV
disease. Prophylaxis begins one month prior to
the onset of
RSV season
and ends as
RSV dis-
ease activity
is waning.
Synagis is a
monoclonal
antibody
given to
high risk
infants and
children
under two
years of age
during the
RSV sea-
son.
The medication is given as an intramuscular
injection every four weeks.
Synagis is given to Kaiser Permanente
members at a single clinic site, which will be held
on alternate Saturdays at the Kaiser Permanente
Gwinnett Medical Office throughout the RSV
season. Clinics will be held beginning Saturday,
Sept. 27, and will run through Saturday, March
28. The only exception to receiving medication
at the clinic are children on home ventilators for
whom special arrangements may be made.
You may refer a patient for evaluation for
Synagis clinic by completing the Synagis clinic
referral form in KP Online-Affiliate or completing
a paper referral form, which can be found on the
Provider Web site (http://providers.kp.org/ga),
and faxing to 770-496-3405.
All referrals are reviewed by the medical
director of Kaiser Permanente Synagis clinic then
forwarded to clinic nursing staff. Your patient will
be contacted by the clinic staff for the initial
Synagis clinic appointment. If you have any
questions, call 770-496-3482. If your patients
have any concerns, they may contact the Kaiser
Permanente Synagis clinic staff at 770-677-6211.
Network News - Fall 2008 7
KP, Piedmont Healthcare Contract News
K
aiser Permanente’s contract with longtime community partner
Piedmont Healthcare has been expanded, effective July 1, 2008.
The contract allows most members to utilize services at Piedmont
Hospital, Piedmont Fayette Hospital and now Piedmont Mountainside
Hospital and Piedmont Newnan Hospital.
The expanded contract covers inpatient and outpatient services, and applies to members of Kaiser
Permanente’s commercial health benefit plans. Piedmont Healthcare is one of the state’s largest health-
care systems.
Grady Health System Receives $5 Million Gift from KP
K
aiser Permanente recently gave a $5 million gift to
Grady Health System to improve access to care
for the uninsured and to support its trauma services.
The gift will fund the care of 1,000 low-income unin-
sured patients with chronic illnesses; purchase a fleet
of 10 new “green” ambulances and equipment for
Grady’s Level I Trauma Center.
“As a non-profit health plan, Kaiser Permanente
understands and appreciates the important safety net
role Grady has in our community. Grady is the largest
safety net hospital in Metro Atlanta serving many of
those most in need. We at Kaiser Permanente want to
do our part to help it continue to serve as such a vital
resource,” said Peter Andruszkiewicz, president of
Kaiser Permanente of Georgia.
In addition to this Grady contribution, Kaiser
Permanente is donating $1.5 million to smaller safety
net organizations in metro Atlanta. The organization
also has a program that offers subsidized health insur-
ance for uninsured, income-eligible persons.
A portion of the $5 million gift to Grady Healthy System
will purchase a fleet of 10 “green” ambulances like the
one seen above.
Important News about Diabetes Eye Exams
D
iabetes is the leading cause of blindness in
the United States. High blood sugar can
damage blood vessels in the retina, and when
they are damaged, they can leak fluid or bleed,
causing the retina to swell and form deposits.
This is an early form of diabetic retinopathy called
background retinopathy.
Please remind your Kaiser Permanente patients
with diabetes that it is very important to see their
eye doctor at least once a year to have a dilated
retinal exam performed to detect signs of
retinopathy. The cost for this exam is a copay-
ment based on a member’s individual benefit
plan.
For a list of the Kaiser Permanente contracted
eye care providers, please have your Kaiser
Permanente patients visit kp.org or contact Kaiser
Permanente Customer Service at 404-261-2590.
Network News is a quarterly
publication for the Kaiser
Permanente of Georgia affiliated
community network.
Please send questions and comments
Editorial Board/Contributors
Editor
Tatyana Kelly
Layout/Design
Billy Auer
Kaiser Foundation Health Plan of Georgia, Inc.
Nine Piedmont Center
3495 Piedmont Rd. N.E.
Atlanta, GA 30305-1736
Kim Barbero
Kristen Berger
Barbara Brown
Debra Carlton, MD
Juanita Cone, MD
Bethany Connor
Cheryl Earls
Donna Edwards
Linda Fox
Steve Giller
Henrietta King
Patricia Lewis
Earl Thurmond, MD
Anne Whitlock
Harold Wittcoff, MD
Kaiser Permanente Names New PresidentP
eter Andruszkiewicz has been named the president
of Kaiser Permanente of Georgia. After serving as
interim president since April, 2008, Andruszkiewicz has
worked collaboratively with the Health Plan leadership
team, the Southeast Permanente Medical Group, Inc.
and the Region’s board of directors in addressing a
number of key issues.
Selected after a national search, Andruszkiewicz has
more than 25 years of experience as a senior executive
in the health care industry. His breadth of experience
makes him an outstanding choice to continue in his role as regional president.
Andruszkiewicz joined Kaiser Permanente in 2005 and has served in a number
of executive capacities in national accounts. His work in the Regions Outside
California (ROC) include managing health plan operations and driving perform-
ance improvement in six ROC regions that serve more than 2.3 million mem-
bers. He had a key role in efforts to improve health plan capabilities and to
leverage technology investments. He also helped build a stronger relationship
between Marketing, Sales, Service and Administration and the regional presi-
dents and executive medical directors.
Before joining Kaiser Permanente, Andruszkiewicz spent 18 years with CIGNA
HealthCare, most recently as senior vice president of Middle Market Segment.
In addition, he served for four years as chief marketing officer at Blue Cross /
Blue Shield of the National Capitol Area, Washington, D.C.
Peter Andruszkiewicz
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