Provider News
November 2022 Issue
August 2022 Issue 
May 2022 Issue
February 2022 Issue

Bulletins

• Mandatory Cultural Competency Training for SelectHealth Providers (November 8, 2022) 
• SelectHealth Supports PrEP Aware Week (October 20, 2022)
• Closing Care Gaps in Vision, Dental, and Behavioral Health (October 13, 2022)
• VNSNY CHOICE is now VNS Health (October 3, 2022)
• We’re Changing Our Name (September 29, 2022)
• Protecting Patients Living with HIV from COVID-19 (August 23, 2022)
• SelectHealth Members Get New ID Cards (August 16, 2022)
• Medicare Webinar: Documentation and Coding for Risk Assessment and Quality (June 30, 2022)
• CAHPS Survey and HEDIS Audit for Total PCPs
  (March 8 ,2022) 
• Independent Assessor Process Started May 16
  (May 23, 2022)
• Important News from VNSNY CHOICE (May 18, 2022)
• Medicare Webinar: Minding the Gaps (April 12, 2022)
• Some Capitation Payments are Delayed to March (February 16, 2022)

Provider News

October 2021 Issue: Two New Medicare Plans Join CHOICE Family

August 2021 Issue

April 2021 Issue

February 2021 Issue 

Bulletins

• Closing the Asthma Medication Ratio Gap (October 19, 2021)
• Your VNSNY CHOICE Total Patients May Be Surveyed About Care You Provide
  (March 2, 2021)
• Alert Your Vendors: New Partner Handling CHOICE Online Transactions (February 25, 2021)
• Diagnosing and Treating Opioid Use Disorder (OUD) During COVID-19 (January 5, 2021)

Provider News

November 2020 Issue

August 2020 Issue

January 2020 Issue

Bulletins

• Appeal a Claim or Dispute a Claim? (December 8, 2020)
• Provider Disclosure Certification Form Required By End of Year (December 1, 2020)
• Reassure SelectHealth Patients Needing Screens and Tests This Fall About the Safety of In-Office Visits (October 1, 2020)
• Real-Time Prescription Benefits from CHOICE Partner MedImpact Going Live October 1 (September 28, 2020)
• CHOICE Total Provider Update: Using Telehealth for HEDIS Measures (September 22, 2020)
• An Important Change for Arranging Non-Emergency Medical Transportation for VNSNY CHOICE Members (August 18, 2020)
• SelectHealth Celebrates SCOTUS Ruling on LGBTQ Rights (June 16, 2020)
• Use of Telehealth Services During the COVID-19 Public Health Emergency for CHOICE Total Medicare Providers (May 14, 2020)
• Use of Telehealth During the COVID-19 State of Emergency (March 27, 2020)
• Emergency Pharmacy Guidance for Prescribers (March 20, 2020)
• Helping Your CHOICE Total Clients with Surveys This Spring: LHCSAs and for PCPs (March 17, 2020)
• Appeal a Claim vs. Dispute a Claim (March 13, 2020)
• Novel Coronavirus and People with HIV: a joint statement from the NYC Health Department and the NYS Department of Health (March 13, 2020)
• Preparedness for COVID-19 (March 10, 2020)
• Opioid safety edits were implemented January 1, 2019 (January 7, 2020)

Provider News

October 2019 Issue

Bulletins

• 2019 Provider Certifications (November 7, 2019)
• SelectHealth Expands to Westchester and Nassau Counties (October 27, 2019)
• Important Changes to Opioid Safety Edits for SelectHealth Providers (October 4, 2019)

This is a reminder that effective February 22, 2021, Availity is the preferred
Electronic Data Interchange (EDI) and Portal vendor for VNSNY CHOICE Health Plans transactions.  

You can also expedite your payments with EFT. To receive ERA files, enroll with Availity directly. 

Please download this Provider News Update for more details.

Resumption of Prior Authorization Activities 7/7/2020:

Given the importance of medical review activities to CMS’ program integrity efforts, CMS will discontinue exercising enforcement discretion for the Prior Authorization Process for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items beginning on August 3, 2020, regardless of the status of the public health emergency. For Power Mobility Devices and Pressure Reducing Support Surfaces that require prior authorization as a condition of payment, claims with an initial date of service on or after August 3, 2020 must be associated with an affirmative prior authorization decision to be eligible for payment.

Additionally, prior authorization will be required for certain Lower Limb Prosthetics (L5856, L5857, L5858, L5973, L5980, and L5987), with dates of service on or after December 1, 2020.

Please see more information here (PDF). The Required Prior Authorization list can be found here (PDF).

Cabenuva is on the pharmacy formulary for our Medicare plans. If you would like to initiate a plan member on Cabenuva, please send a prescription to a specialty pharmacy. 

As part of a continued effort to alert VNS Health Total (HMO D-SNP) primary care physicians (PCPs) of member health changes in real time, we are pleased to announce the 2021 rollout of a new report containing member inpatient admission or discharge information.

Member PCPs should expect to receive this alert each time a member is admitted and discharged from an inpatient facility via secure email or secure e-fax.

We request that providers review the information upon receipt and enter all pertinent information into the patient’s medical record. Within the alert providers will find the following:

• Member demographic information
• Admitting provider, diagnosis, and date
• Discharge diagnosis, date, and length of stay (if applicable)

Other transitions of care best practices include:

• Schedule follow-up visits within 14 days of discharge (in office, in home, or telehealth)
• Conduct a medication reconciliation during a visit within 14 days of discharge, educating the patient or primary caregiver on any changes
  • Tip: code medication reconciliation in your EMR to close quality gaps electronically:
    • TCM visit codes meet the Medication Reconciliation measure and close gaps
      • CPT code 99496 or 99495 for visits within 7 or 14 days, respectively
    • CPT II ® code 1111F meets the measure for visits between 1-30 days of discharge
  • Review any potential requirements for tests and treatments, and follow up as needed
  • Coordinate with the Health Plan Care Manager for assistance with referrals for in-network specialists and other services

These alerts are aimed at assisting providers in meeting the HEDIS® Transition of Care (TRC) measure, among others. Two TRC measure components include:

• Documentation in the medical record that inpatient admission notification was received on the day of admission or the two following days (3 days total).
• Documentation in the medical record that discharge information was received on the day of discharge or the two following days (3 days total).

Thank you for your dedication to our Health Plan members and their health.

If you have any questions, or if you would like transitions of care workflow training for your office staff, please contact the Quality Management Team at: [email protected].

VNS Health Total (HMO D-SNP) is pleased to announce its designation as a CMS Innovation Center Model participant for the Hospice Benefit Program. Learn more on our Hospice Benefit FAQ page.

New Guidelines for Telehealth Interventions in four HEDIS Quality Measures
(For VNS Health Total Providers Only)

Effective 9/1/2022: MedImpact Healthcare will deny SelectHealth from VNS Health’s Medicaid Prescription claims if they are submitted from providers (practitioners and pharmacies) that are NOT enrolled with New York State Medicaid Program.

To initiate provider enrollment with the New York State Medicaid Program, visit: https://www.emedny.org/info/providerenrollment/.

For more information, please check this communication provided to pharmacies.

New SelectHealth ID cards were recently mailed to all members. They look virtually the same as the old ID cards. The only difference is that they bear the plan’s new name, SelectHealth from VNS Health. Learn more.

OnTrackNY is an innovative treatment program for adolescents and young adults who have had unusual thoughts and behaviors or who have started hearing or seeing things that others don’t. OnTrackNY helps people achieve their goals for school, work, and relationships. Programs are located throughout New York State.

Eligibility criteria

The program is for adolescents and young adults between the ages of 16 and 30 who have recently begun experiencing psychotic symptoms, such as hallucinations, unusual thoughts or beliefs, or disorganized thinking, for more than a week but less than 2 years.

Services offered by OnTrackNY

OnTrackNY utilizes a “shared decision making” model and involves:

• Comprehensive treatment using evidence-based practices delivered by an integrated clinical team specializing in early psychosis.
• Psychiatric treatment, employment and educational support, substance abuse treatment, family education and support, CBT-informed individual psychotherapy, and other services as needed.

How to make a referral to OnTrackNY

Contact your nearest OnTrackNY program site.

The basics

SelectHealth from VNSHealth covers Cabenuva, an injectable treatment for HIV that is administered by a physician. Cabenuva is covered as a medical benefit directly by SelectHealth so you do not need to send a request to our pharmacy benefits manager, MedImpact. The medication is supplied by a central pharmacy directly to the provider who will administer it.

Starting a SelectHealth patient on Cabenuva requires the prescriber to fill out this Prior Authorization Request Form and fax the completed form to 646-459-7731.

The request will be reviewed by the SelectHealth Medical Management team according to FDA guideline criteria. For ongoing treatment, the prescriber will need to fill out and fax in a Cabenuva continuation form every six months.

If you have any questions about this process, please call 1-866-791-2215, Option 3.

• For initial Cabeuva requests, please: Fill out this Prior Authorization Request Form and fax it back to 646-459-7731.
• For continuation Cabenuva requests: Fill out this Prior Authorization Request Form and fax back to 646-459-7731.

Call 1-866-791-2215, Option 3, with any questions.

Initial Request Criteria 

A request to start your patient on Cabenuva requires an approval from our Medical Management team. Our guideline criteria for Cabenuva are:

1. Does the member have a diagnosis of human Immunodeficiency virus type 1 (HIV-1) infection?
2. Is the member 18 years of age or older?
3. Is the member virologically suppressed (HIV-1 RNA less than 50 copies per mL)? Please note we expect VL load to be drawn every 6 months while on Cabenuva therapy.
4. Please provide last VL and Date
5. Is the member on a stable antiretroviral regimen with no history of treatment failure and with no known or suspected resistance to either cabotegravir or rilpivirine?
6. Is the member currently taking on any of these medications listed? These medications are contraindicated:
   1. Anticonvulsants: Carbamazepine, oxcarbazepine, phenobarbital, phenytoin
   2. Antimycobacterials: Rifabutin, rifampin, rifapentine
   3. Glucocorticoid (systemic): Dexamethasone (more than a single-dose treatment)
   4. Herbal product: St John’s wort (Hypericum perforatum)
   5. Any other antiviral medication for the treatment of HIV-1 and hepatitis
7. Did member receive an oral lead in dose with Vocabria (cabotegravir 30-mg) and Edurant (rilpivirine 25-mg) oral tablets, both taken once daily with a meal, for approximately 1 month (at least 28 days) to assess tolerability? *Please note oral lead in dose is optional*
8. Do you attest that the member has no issues with adherence and is coming in monthly for their injections?

Payment

SelectHealth does not require the presciber or facility to pay for Cabenuva and then request reimbursement (so called “Buy and Bill”), since this is not possible at many sites of care. Instead, we have arranged to pay directly once the medication is approved.

Based on updated FDA guidelines, the oral lead in is no longer required but remains an option. In addition, administration every two months at a higher dose is an available option. The application form requires selecting the dose you would like your patient on.

Sarepta

New York State has executed a state-direct supplemental rebate agreement with Sarepta for drugs used to treat Duchenne Muscular Dystrophy (DMD). This policy went into effect on April 1, 2022.

Check the Prescriber Billing Codes in the Reference Guides and Fact Sheets section of the Provider Toolkit for details.

Practitioner Dispensing Policy Clarification of DOH Billing Guidance (Effective: 10/4/2022)

Check the Prescriber Billing Codes in the Reference Guides and Fact Sheets section of the Provider Toolkit for updated information.

As a SelectHealth network provider, you may find yourself in a position to provide services for a new group of Medicaid Managed Care (MMC) enrollees who require trauma-informed care: children/youth in direct placement foster care and in the care of Voluntary Foster Care Agencies (VFCA). 

Please download this Letter for Network Providers for more information about coordinating services, pharmacy benefits, and the Initial Medical Assessment that is required within the first 30 days of the child or youth’s placement.

On December 22, 2021, Governor Hochul signed a new law that amends the Social Services Law and the Public Health Law, which relate to medication for the treatment of substance use disorders. Effective March 22, 2022, prior authorization (PA) will not be required for medications for the treatment of substance use disorder prescribed according to generally accepted national professional guidelines. Prescriptions written outside of accepted guidelines for the treatment of substance use disorder may be subject to Prior Authorization.

A Single Statewide Medication Assisted Treatment (MAT) Formulary was implemented on October 1, 2021. The Single Statewide MAT Formulary aligns coverage parameters across New York State (NYS) Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC).

Download this provider notice for summary of changes. 

For Prescribers:

Effective March 22, 2022, prescriptions for brand name multi-source drugs will be filled with generic equivalents, as required by the NYS Social Services and Education Law—unless the prescriber indicates “DAW” and “Brand Medically Necessary (BMN)” on the prescription. The prescriber must also make a notation in the medical record of the Medicaid member stating that the drug is “BMN” and the reason that a brand name multi-source drug is required.

Please check this updated pharmacy communication regarding upcoming MAT Formulary Alignment updates for guidance on billing successfully for Brand medications when Generic equivalents exists.