SCOPE | Provider Update

June 2024

Clinical Matters

Proactively managing pregnancy and postpartum complications

Awareness of maternal warning signs helps with early identification and treatment; online toolkit provides helpful resources.

As a health care provider, you play a critical role in eliminating preventable maternal morbidity and mortality. That’s why Independent Health has created an evidence-based Maternity Toolkit for Providers and Patients to assist you with educational content, tools, and resources.

The risk of pregnancy-related complications continues for one year after a pregnancy ends. It’s crucial for any health care professional to identify patients who are pregnant or who were pregnant in the last year and to be aware of the urgent maternal warning signs from complications.

Always ask if your patient is pregnant or was pregnant in the last year.

Pregnancy or postpartum status may not be something your patient or their support thinks about sharing, particularly with their primary care physician, but it could be the difference in making an accurate and timely diagnosis.

According to the Centers for Disease Control and Prevention (CDC), some warning signs include:

Severe headache
Dizziness or fainting
Changes in vision
Fever
Trouble breathing
Overwhelming tiredness
Chest pain
Severe belly pain
Severe nausea and vomiting
Severe swelling
Thoughts about harming self or baby

Immunizations

The Advisory Committee on Immunization Practices (ACIP) clinical guidelines recommend that all women who are pregnant or who might be pregnant in the upcoming influenza season receive inactivated influenza vaccines. ACIP also recommends that pregnant women receive one dose of Tdap during each pregnancy, preferably during the early part of gestational weeks 27–36, regardless of prior history of receiving Tdap.

Important Reminders

Always discuss immunization status.
Screen patients for depression utilizing an evidenced-based, validated screening tool (ex: PHQ2/9), and refer to a Behavioral Health Specialist, if the patient has a positive screen.
Ensure linkage with an Obstetrician or Nurse midwife for early prenatal care, if pregnant.
Perform a medication review and assess for potential contraindications.
Document pregnancy information and any referrals made.

The Maternity Toolkit is posted on the secure provider portal under the Resources Tab.

Need Help?

To assist you in helping patients manage uncontrolled chronic diseases or for care coordination needs, please call (716) 635-7822 from Monday – Friday, 8 a.m. – 5 p.m. and one of our Care Managers will be assigned to assist.

Helpful Resources

Warning Signs Poster from the CDC: Urgent Maternal Warning Signs Educational Materials
Dietary Guidelines for Americans 2020-2025: Professional Resources | Dietary Guidelines for Americans
Patient Health Questionnaires: Administering the Patient Health Questionnaires 2 and 9 (PHQ 2 and 9) in Integrated Care Settings (ny.gov)
Hear Her Campaign for Health Care Professionals CDC

Submit 2024 Gaps-in-Care corrections through the provider portal

Practices may now submit gaps-in-care corrections for 2024 through the provider portal.

Gaps in Care Correction allows for submitting medical record documentation to “correct” inaccuracies in quality measure results due to a variety of reasons, including:

Encounters or lab values not available to the health plan
Exclusions from a historical event (e.g., mastectomy)
Service that was rendered under a different payer

If the correction is accepted, it will be reflected in an update to your, and Independent Health’s, quality rates, which allows for:

A more accurate depiction of the quality of care that was rendered
More accurate quality program reporting
More targeted quality improvement effort

The following resources and guides are available online in our secure provider portal. Both are posted in the Document Manager.

The Gaps in Care Correction Process User Guide, which has details on how to submit corrections.
The Correctible Measures for 2024.

You may also view a webinar about the Gaps in Care Correction Process.

The last day to submit Gap in Care Corrections for 2024 will be Tuesday, December 31, 2024.

If you have questions about the gaps in care correction process, performance reports or anything related to our provider portal:

Contact your Independent Health Physician Engagement Specialist
Email ProviderPortal@independenthealth.com

Glycemic status assessment for patients with diabetes measure

Updated measure now allows use of GMI

The Glycemic Status Assessment for Patients with Diabetes measure has been updated to allow not only a HbA1c from a lab but also will allow the use of glucose management indicator (GMI).

This measure is still looking for the last HbA1c or GMI of the measurement year. In order to be compliant for the measure, the HbA1c or GMI needs to be >8.0%.

Members who fall into this measure should still continue to have HbA1c tests completed, but for members utilizing a continuous glucose monitor that has the ability to calculate a GMI can also be used. Please use appropriate CPT II codes to capture HbA1c results.

When submitting corrections on the Provider Portal for this measure, please include the final lab report or full GMI report from your EMR. We cannot accept Continuity of Care Documents (CCD) as documentation per NCQA requirements.

For further measure requirements, please refer to the HEDIS Provider Guide and Reference Manual.

Upcoming member campaigns to encourage our members to take greater control of their health

Throughout the year, the Health Care Services and Population Health Management Departments deploy various tactics to encourage members to take a more active role in their health.

Gap in Care Reminder Calls

Independent Health’s Member Servicing team will perform telephonic outreach to provide education and encourage members with an open gap in care to reach out to their provider to schedule the appropriate appointments and/or get a prescription to complete the screening.

Medicaid Managed Care members who have open gaps for: breast cancer, colorectal, and/or cervical cancer screenings.
Medicaid Managed Care and Child Health Plus members (ages 9-12) who have started but not completed the series for HPV vaccinations
Medicare Advantage members who have open gaps for: breast cancer, colorectal, and/or eye exams for members with diabetes
Timeframe: Call campaign is scheduled to begin in June 2024

Social Determinants of Health Screening

This telephonic outreach campaign will engage targeted Medicare Advantage members in a conversation around screening for social determinants of health to identify any needs the member has for food, housing, and/or transportation. If a need is identified, Independent Health will assist the member in making a connection to a community resource to address the need.

Outreach method: Outbound telephone call campaign
Target members: Medicare members identified with social risk factors including those with low-income subsidy or dual enrollment in Medicaid
Timeframe: Campaign will begin in June and run throughout 2024

Formulary and Policy Changes

Stay up-to-date on Independent Health's pharmacy policies and formulary updates.

Formulary Deletions

The following documents are available in PDF. Please download them, as they contain important information and updates.

Medicare Advantage formulary deletions for individual and group plan members, effective June 1, 2024.
Pharmacy Benefit Dimensions 3-Tier formulary deletions, effective June 1, 2024.
Pharmacy Benefit Dimensions 5-Tier formulary deletions, effective June 1, 2024.

View the most up to date versions of Independent Health’s policies when logged in to our provider portal.

Magellan Rx, administered by Magellan Rx Management, reviews select specialty drug prior authorization requests on Independent Health’s behalf. To view Magellan Rx policies for the drugs that they review, click here.

Independent Health's drug formularies
Access Independent Health's drug formularies here.

To obtain a hard copy, please contact Independent Health Provider Relations by calling (716) 631-3282 or 1-800-736-5771, Monday through Friday from 8 a.m. to 6 p.m.

In the News

Independent Health again named one of top health plans in region by members - The Buffalo News, May 31, 2024.

Independent Health has been ranked as the second-highest health plan for member satisfaction in the New York region, according to a study conducted by J.D. Power of U.S. commercial member health plans.