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Network Matters
News and Information for the
Harvard Pilgrim Health Care Network

August 2015

Highlights

ICD-10 Transition & Paper Claims Submission

As you are aware, Harvard Pilgrim will be moving from ICD-9 diagnosis and procedure codes to the significantly more extensive ICD-10 code sets on the October 1, 2015 compliance date mandated by the Centers for Medicare and Medicaid (CMS).

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New HEDIS Measure:  Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM)

The new Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM) HEDIS measure calculates the percentage of children ages 1–17 who have had two or more antipsychotic prescriptions filled and at least one metabolic test for blood glucose HbA1c, and at least one test for low-density lipoprotein cholesterol (LCL-C) or total cholesterol each year.

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Prior Authorization Required for Duexis and Vimovo

Beginning October 1, 2015, Harvard Pilgrim will require prior authorization for coverage of the combination non-steroidal anti-inflammatory drugs (NSAIDs) and acid-reducing therapies Duexis (ibuprofen/famotidine) and Vimovo (esomeprazole/naproxen) on the Premium formularies.

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Prior Authorization Required for Entresto

Effective immediately, Harvard Pilgrim is covering the medication Entresto with prior authorization. In July, the U.S. Food and Drug Administration (FDA) approved Entresto — which is a combination agent containing the novel neprilysin inhibitor sacubitril and the angiotensin II receptor blocker (ARB) valsartan — for use in the treatment of chronic heart failure.

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Reminder: Save Time and Paper with Harvard Pilgrim’s Electronic Tools

As a reminder, Harvard Pilgrim offers easy-to-use electronic tools to complete many transactions more quickly and efficiently.

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HPHCURRENT EVENTS

ICD-10 Transition & Paper Claims Submission

CLINICIAN CORNER

New Clinical Medical Policies

Medical Criteria for Inverted Nipple Repair

The Safe Storage and Disposal of Opioids

New HEDIS Measure:  Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM)

Prior Authorization Required for Duexis and Vimovo

Prior Authorization Required for Entresto

ICORE Healthcare Becoming Magellan Rx Pharmacy, LLC

Coordination of Care for Transgender Patients

Harvard Pilgrim’s EatRight Rewards Promotes Wellness

OFFICE ASSISTANT

Bilateral Reimbursement

Update Coming to HPHConnect for Providers

Reminder: Save Time and Paper with Harvard Pilgrim’s Electronic Tools

PUBLICATION INFORMATION

Eric H. Schultz,
President and Chief Executive Officer

Robert Farias,
Vice President, Network Services

Annmarie Dadoly,
Editor

Joseph O'Riordan,
Writer

Kristin Edmonston,
Production Coordinator