March 2025

Adherence to statin medications can aid in risk reduction of clinical atherosclerotic cardiovascular disease (ASCVD) for patients living with cardiovascular disease (CVD) and/or diabetes.

The American Diabetes Association recommends that individuals with the following risk factors should be treated with a statin, regardless of their baseline LDL cholesterol concentration: 

• individuals living with diabetes or a history of CVD;
• individuals older than 40 years of age without CVD but with CVD risk factors.

As such, the National Committee for Quality Assurance (NCQA) has two unique statin therapy measures, which are included in the Independent Health HEDIS manual on the provider portal.

Statin Therapy for Patients with Cardiovascular Disease (SPC) assesses males 21 to 75 years of age and females 40 to 75 years of age during the measurement year, who are identified as having ASCVD and meet the following criteria:

• Received at least one high or moderate intensity statin medication during the measurement year. 
• Had adherence to the statin medication regimen for at least 80% of the treatment period.
• This is also a Primary Value measure. 

Statin Therapy for Patients with Diabetes (SPD) assesses individuals 40 to 75 years of age with a diagnosis of diabetes and no diagnosis of ASCVD, and who meet the following criteria:

• Members who have received at least one statin medication of any intensity during the measurement year, and;
• Had adherence to the statin medication regimen for at least 80% of the treatment period.
• This is also a Primary Value measure.

Did you know?

Certain adverse reactions to a statin medication may exclude the patient from the measure denominator if properly documented. 

• Diagnosis of active muscle pain and disease, including myalgia, myositis, myopathy, or rhabdomyolysis during calendar year 2025.
• Please refer to the HEDIS manual for a full list of exclusion diagnoses.
• These exclusionary diagnoses may come from claims or chart review data.

New in 2025:

We are now able to accept a historial diagnosis of myalgia or rhabdomyolysis caused by a statin any time during the member’s history. 

One of the following diagnoses must be documented in the medical record progress note. You may upload the diagnoses into the portal through the Gaps in Care Correction process later this spring:

• M62.82, M79.10, M79.11, M79.12, M79.18

Note: We will accept these corrections through the portal; however, they will not fall off your gap reporting until November, 2025, when the new historic exclusions officially go into effect.  

During recent months, the Provider Relations department has received increasingly high volumes of phone calls from third party billing companies asking for claim status. Typically, these callers may have a list of five to 20+ claims they are asking about during a single phone call.  Many of these callers work in call centers so multiple people may call us up to 40 times per day on behalf of one provider practice. Unfortunately, this high volume of claim status phone calls is creating unusually high wait times for all callers. 

Therefore, to improve the experience for all, we will no longer service the following types of claim status calls:

• Claims received fewer than 30 days ago;
• Claims that have been paid or approved;
• Requests to provide lists of claim numbers to the caller;

We will continue to provide information about denied claims that are more than 30 days old. Additionally, we are happy to assist in resolving any claim issues you may need assistance with.  Please be aware that we do require a signed copy of the Business Associate Agreement between your practice and any third party before we release information to them on your behalf.

We ask you to please pass this information on to your billing team.  If you have any questions about this, please call Provider Relations at 716-631-3282 or 1-800-736-5771 Monday through Friday 8:00 a.m. to 5:00 p.m.

As we announced in the fall, Independent Health will add a layer of security to the provider portal by requiring two-factor authentication.

Once this security step is in place on March 3, it will require portal users to confirm their identities by providing two separate credentials: by entering their current password, and by entering a code they receive by email or text message. 

When current users log in on March 3, they will have to indicate their preference to receive the code: either by providing their phone number to receive a text, or by their email.

Two-factor authentication makes it harder for unauthorized users to gain access to a person's devices or online accounts, because the authorized user’s password alone is not enough to pass the authentication check.

To prepare for this change, portal administrators should review their organization’s portal accounts and users to make sure the individuals who have portal accounts are still current and active at their organization. 

The CDC recently removed key clinical guidelines from its website to comply with an Executive Order by the President regarding content related to gender identity, diversity, equity, and inclusion (DEI), and LGBTQ+ issues. This removal of this clinical information has raised significant concerns among healthcare professionals who rely on these guidelines for treating underrepresented and medically vulnerable populations.

While some webpages have started to reappear, leading medical organizations and physician groups have strongly opposed the removal of this crucial information, warning it could hinder disease control efforts and quality care. They are urging Congress to ensure the CDC can continue providing essential information.

Alternative Resources and Support

We have compiled a list of reputable online resources, including from the New York State Department of Health, to support your patient care until this matter is resolved. 

• NYSDOH Lesbian, Gay, Bisexual and Transgender Health - Find links to LGBTQ+ Health and Human Services resources, including but not limited to: The Center of Excellence for Transgender Health, the Gay & Lesbian Medical Association, and the Trevor Project.
• NYSDOH AIDS Institute - Provides multiple resources for both consumers and providers regarding awareness of, and management of, HIV/AIDS, sexually transmitted infections, and viral hepatitis.
• NYSDOH AIDS Institute Clinical Guidelines Program - Review professional treatment guidelines for HIV screening and diagnosis, HIV treatment, pre- and post-exposure prophylaxis, sexually transmitted infections, viral hepatitis, substance use, and primary and specialty HIV care.
• NYSDOH Minority Health Reports & Resources - View a collection of online resources for diverse populations, including women, children, and older adults, racial and ethnic minorities, rural populations, people with disabilities, those with low socioeconomic status, people of various religious groups, and LGBTQ+ populations.
• NYSDOH Sexual Assault Forensic Examiner (SAFE) Program - Important information about the SAFE Program, including post-exposure clinical management of sexual assault, provision of and education about emergency contraception, and links for rape crisis and victim advocacy.
• NYS Office of Mental Health - Visit the NYS Office of Mental Health for valuable information for providers, consumers, consumer advocates, including a directory to help locate mental health programs.
• NYS AIDS Institute Provider Directory - Access a list of local providers for HIV, HCV, PrEP, PEP, Buprenorphine, STI services, Syringe Exchange Programs, Expanded Syringe Access Programs, and Opioid Overdose Prevention Programs.

Ensuring accurate and unbiased guidance about the recognition, management, and prevention of stigmatized health conditions is vital for both personal health outcomes of underrepresented populations and for optimizing public and population health outcomes.

Addressing minority health ensures that all communities, regardless of race or ethnicity, gender or sexual orientation, have access to quality healthcare and resources, reducing health disparities.

By promoting cultural competence and humility in our interactions with all patients, we can create a healthier society where everyone feels valued and supported. Having access to the above information is integral to this common goal.

Drug Formulary Changes

View the formulary changes for the First Quarter of 2025. 

Access Independent Health's drug formularies here.

Drug Policies

The policy changes for the first quarter of 2025 are now available online. Log in to the provider portal to view the changes. Click on "Monthly Policy Updates" under the News tab once you are logged in. 

Search for and view the most current versions of all drug policies when logged in to our provider portal.

Prime Therapeutics reviews select specialty drug prior authorization requests on Independent Health’s behalf. View Prime Therapeutics policies for the drugs that they review.

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 5 p.m.