SUMMER 2013
this issue
Care Coordination p.1
ICD-10 p.2
Meridian’s Quality
Improvement Program p.3
What to do when your
requested service is denied p.4
PrimeMeridian
IOWA
CARE COORDINATION – Who is it right for?
Do you have a Meridian member under your care you
would like to refer for Care Coordination? Members we
seek to enroll in Care Coordination are:
• Pregnant members
• Adults and children with special needs
• High-risk and high-cost populations with multiple
health and social needs
• Members requiring post-hospitalization assessment
and follow-up
• High-ED utilizers requiring education and
communication with their PCP
• Members with level 3 chronic conditions or more than
one chronic diagnosis, regardless of risk stratification
• Members with medical needs who are also suffering
from psychosocial and behavioral health risk factors
NLPS02 IA
These members could benefit from our integrated team
approach, with team members specialized in medical,
children’s special health care services, maternity, highED, medical and children with special needs.
Providers refer any Meridian member to the
Care Coordination program by:
1. Notifying Meridian through the Provider Portal
• Login to the Provider Portal
(www.mhplan.com/ia/mcs)
• Select “Member” on the left menu
• Enter the Member ID number
• Click “Notify Health Plan” at the bottom of
the “Demographics” screen
• Select “Case Management” (middle tab)
and fill out the reason for referral
2. Completing the “Care Coordination Referral
Form” and faxing it to Meridian. To get the form:
• Go to www.mhplan.com/ia/providers
• Click on “Documents & Forms” on the left side
• Fax the completed form to 515-802-3560
• Request a physical copy from your local
Provider Network Development
Representative when needed
If you have questions or would like to refer a member by phone,
call our Member Services department at 877-204-9132.
Submit Medical Records
Electronically with Meridian
Meridian wants to work with you to collect
Electronic Medical Record (EMR) data. How does
this benefit you?
• Maximize your HEDIS® and PCMH bonus
payments check
• Less time spent faxing
• Less onsite medical record review
• Decreased administrative burden
• Improved accuracy of diagnoses and
health outcomes
HOW DO YOU GET STARTED
WITH MERIDIAN?
Meridian can help you develop a template or
revise an existing one (if you already submit EMR
data with other organizations). We can connect
our Information Technology (IT) team with your IT
staff and initiate the process. Follow these steps
to register:
1. Contact your Provider Network
Development Representative
2. Meridian will send you an EMR template
with instructions
3. Email your test data to Meridian
4. Meridian sends your SFTP (secure) login
and instructions
5. Load your EMR data into the SFTP site
6. A confirmation email appears with a
successful upload
OCTOBER
Have You Heard?
ICD-10
Effective in 2014
Starting on October 1, 2014, the
Centers for Medicare and Medicaid
Services (CMS) require all ICD-9
codes be replaced with ICD-10 codes
for all HIPAA-covered entities. The
new ICD-10 codes use updated
terminology and allow for greater
specificity and more clinical detail.
The number of diagnosis/procedure
codes expands from about 17,000 to
over 150,000. The code expansion
supports the collection of useful
clinical data to measure and monitor
healthcare services and population
health.
What should you do to prepare for the
conversion for ICD-10? The transition
from approximately 17,000 codes to
more than 150,000 ICD-10 codes
requires immediate attention to ensure
clinical and business processes and
systems meet the CMS compliance
date of October 1, 2014. Areas likely
to be impacted include coding, billing
and clinical documentation. For
additional information regarding ICD10 Implementation, please visit www.
cms.gov/Medicare/Coding/ICD10.
Meridian currently performs impact
analysis and internal testing of our
business processes, in-house systems
and external systems to ensure a
smooth transition to ICD-10 code
use. CMS advises providers, payers
2
and vendors begin testing with each
other on October 1, 2013. Testing
commences through October 1, 2014.
CMS released Generic Equivalence
Mappings (GEMs) to identify the code
mapping from ICD-9 to ICD-10 codes.
Meridian is following CMS guidance
and using the CMS GEMs to transition
our systems and business processes.
Claims submitted with the date of
service on or after the compliance
date of October 1, 2014 must be
submitted using ICD-10 CM and PCS
coding. Claims that are submitted
with the date of service on or after
October 1, 2014 using ICD-9 CM or
PCS coding will be rejected for invalid
coding.
Meridian will accept ICD-9 coding on
or after October 1, 2014 only if the
date of service or date of discharge
is prior to October 1, 2014. Meridian
continues to follow our procedure of
accepting claims up to one year after
our date of service.
A list of ICD-10 FAQs can be found
under the Bulletins/Updates tab at
www.mhplan.com/ia/providers. More
information about Meridian’s transition
to ICD-10 Meridian’s ICD-10 testing
will be shared and posted on the
website when available.
MERIDIAN’S
Quality Improvement
Program
Meridian Health Plan would like to THANK
all of our NETWORK PROVIDERS for helping
us ACHIEVE THE GOALS identified in our 2012
Quality Improvement Program.
Baseline results for the 2012
performance measures are being
established at this time and will be
provided in the Quality Improvement
Annual Evaluation. Based upon interim
results, Meridian met performance goals
in Adult Access to Care, Cervical Cancer
Screening, Diabetic Eye Exams and
timely Prenatal and Postpartum care. In
Pediatric Care measures, Meridian met
performance goals for Lead Screening
and Well-Child Visits in the third, fourth,
fifth and sixth years of life.
Meridian has developed three
Performance Improvement Projects
(PIPs). Based on interim baseline results,
Meridian achieved the set goals for four
of the ten measures associated with
the Practitioner Adherence with Clinical
Practice Guidelines PIP. We achieved the
set goals for eight of the ten measures
associated with Improving Continuity and
Coordination between Medical Care and
Behavioral Health Care for the Perinatal
Population PIP. Meridian did not meet
the set goals for the two measures
associated with Improving Continuity
and Coordination between Medical
Care following an Inpatient Hospital
Admission PIP.
Meridian is actively collecting results from
its Member Experience Survey. Interim
results look promising, with scores
exceeding the 90th percentile in the
following measures:
Clinical Practice
and Preventive
Health Guidelines
Available on Web
Meridian Health Plan
encourages our providers to
• Rating of the health plan
use evidence-based clinical
• Meridian customer service
practice guidelines (CPGs).
• Rating of the PCP
Our Quality Improvement
• Getting care quickly
Committee approves and
• Office staff treats you with
courtesy/respect
adopts CPGs for prevention,
• PCP explains things so you
understand
medical and behavioral health
diagnosis and management of
• PCP shows respect for what
you say
conditions. These correspond
• PCP spends enough time
with you
of care and clinical treatment
Meridian encourages providers to
participate in all quality improvement
activities. We encourage providers
to support the Quality Improvement
Program by offering to participate on our
Provider Advisory Committee (PAC) and/
or Quality Improvement Committee (QIC).
For more information about Meridian’s
Quality Improvement Program, please
refer to the Provider Manual, available at
www.mhplan.com/ia.
with well-accepted standards
for specific conditions. If you
ever need to access Meridian’s
CPGs or Preventive Health
Guidelines, visit our website
at www.mhplan.com/ia and
click on “Providers” or call
our Quality Improvement
department at 515-802-3500
for a printed copy.
To request a printed copy of the manual please call
Provider Services at 877-204-8977.
3
Utilization
Management
Decision-Making
Providers may obtain the
criteria used to make Utilization
Management (UM) decisions by
accessing the Provider Manual
on our website or by calling
877-204-9072 for a printed
copy.
UM decision making is based
only on appropriateness of
care and service and existence
of coverage. Meridian Health
Plan and its customers do not
specifically reward practitioners
or other individuals for
issuing denials of coverage or
care. Financial incentives for
UM decision makers do not
encourage decisions that result
in underutilization.
Provider Manual:
2013 Edition
The 2013 Meridian Provider Manual
contains updated and helpful
information on these areas:
• Updated provider agreement
language
• UM communication information,
including business hours and
contact information
• List of rights and responsibilities
as a contracted Meridian provider
• Meridian member rights and
responsibilities
• Disease Management programs
and services available to
members
To review the Provider Manual, visit
www.mhplan.com/ia/providers and
click on “Provider Manual.” From
there you can download and save a
copy for yourself. You can request
a printed copy or a copy on CD
from your local Provider Network
Development Representative or the
Provider Services department at
877-204-8977.
4
What to Do When Your
Requested Service is Denied
There are several options available to providers when a requested service is denied:
• Call 888-322-8843 x1901 for a peer to peer discussion with a Meridian physician
who was involved the in the denial decision
• Fax additional information to 313-463-5259 within 10 days following a denial for
a reconsideration
• Send a written appeal within 30 days of receiving a response along with any
additional supporting clinical documentation to the Appeals and Denials
department at:
Meridian Health Plan – Appeals & Denials
666 Grand Avenue, 14th Floor
Des Moines, IA 50309
The Appeals department is available for assistance Monday through Friday, from
8 a.m. to 5 p.m. at 888-322-8843 x1302.
Local Meridian Member Advisory Committee
As part of Meridian’s initiative to reach out to members, the Quality Improvement
department has implemented a Member Advisory Committee (MAC) in Iowa. The MAC
meets on a quarterly basis (the first two meetings were held on January 15th and April
25th). Specific topics are reviewed with current members to obtain feedback on the
health plan and the services provided, and to understand their perspective. This forum
allows members to speak freely about what is working for them, what Meridian can do to
improve and to identify any barriers the members have to obtaining preventive healthcare
services. The Quality Improvement department then uses this information to develop or
revise educational materials and implement strategies, including member incentives and
participation in community events, to assist them in obtaining preventive healthcare.
Iowa Medicaid is Expanding!
Meridian is currently set to expand our
services into Scott County! This brings our
tally to 6 new counties in 2013, for a total
of 13 counties served!
Lyon
Osceola
Dickinson
Emmet
Sioux
O'Brien
Clay
Palo Alto
Plymouth
Cherokee
Buena
Vista
Ida
Sac
Woodbury
Monona
February – 3 (Cedar, Jasper, Johnson)
June – 2 (Buchanan, Greene)
July – 1 (Scott)
Winnebago
Worth
Mitchell
Howard
Hancock
Cerro
Gordo
Floyd
Chickasaw
Wright
Franklin
Butler
Hardin
Grundy
Kossuth
Pocahontas Humboldt
Calhoun
Webster
Crawford
Carroll
Shelby
Audubon
Guthrie
Dallas
Polk
Cass
Adair
Madison
Warren
Harrison
Greene
Hamilton
Boone
Story
Fayette
Clayton
Buchanan
Delaware
Bremer
Black
Hawk
Dubuque
Jones
Tama
Benton
Linn
Poweshiek
Iowa
Johnson
Marshall
Jasper
Winneshiek Allamakee
Clinton
Cedar
Scott
Muscatine
Pottawattamie
Mills
Fremont
Montgomery Adams
Page
Taylor
Marion
Jackson
Mahaska
Keokuk
Washington
Union
Clarke
Lucas
Monroe
Wapello
Jefferson
Ringgold
Decatur
Wayne
Appanoose
Davis
Van Buren
Henry
Lee
Louisa
Des
Moines