Notices, News, and Updates

Provider News and Updates

In the rapidly transforming world of health care, we understand how important it is for you to stay up to date on changes that affect you, your practice, and your patients. Below are notices, recommendations, and updates that can help you keep track of changing standards and regulations. Check back regularly for new postings.

Newsletters and Bulletins

Read the latest issue—Fall 2022

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New Member ID Cards for 2023

Effective January 1, 2023, members of the health plans from VNS Health have new member ID cards, reflecting the new names of their plans.

Medicare Plans

We have three Medicare plans: VNS Health Total (HMO D-SNP), VNS Health EasyCare (HMO), and VNS Health EasyCare Plus (HMO D-SNP). Our three Medicare plan cards look like this. You can find the plan name on the “Plan” line.

VNS Health MLTC

You may not see ID cards from our Managed Long Term Care plan, VNS Health MLTC, as they aren’t required to be shown for services. But in case you do, they’ll look like the card on the right after January 1.

SelectHealth

We changed the name of our Medicaid special needs plan to SelectHealth from VNS Health and mailed out new ID cards last summer. SelectHealth member ID cards have a distinct look.

Guideline and Policy Updates

For All Health Plan Providers

For VNS Health Medicare Providers

As part of a continued effort to alert VNS Health Total (HMO D-SNP) 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 via secure email or secure e-fax each time a member is admitted and discharged from an inpatient facility.

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 electronic medical record 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 and 30 days of discharge
- Review any potential requirements for tests and treatments, and follow up as needed
- Coordinate with the health plans 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 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].

For SelectHealth from VNS Health Providers

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 1-646-459-7731.

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 6 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 1-646-459-7731.
For continuation Cabenuva requests, fill out this Prior Authorization Request Form, and fax it back to 1-646-459-7731.

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 as follows:

Does the member have a diagnosis of human immunodeficiency virus type 1 (HIV-1) infection?
Is the member 18 years of age or older?
Is the member virologically suppressed (HIV-1 RNA less than 50 copies/mL)? Please note that we expect VL load to be drawn every 6 months while the member is on Cabenuva therapy.
Please provide last VL and date.
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?
Is the member currently taking any of the following contraindicated medications:
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
Did the 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 that an oral lead-in dose is optional.
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 prescriber or facility to pay for Cabenuva and then request reimbursement (“buy and bill”), because 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 2 months at a higher dose is an available option. The application form requires selecting the dose you would like your patient to be on.