- ICD-10 implementation information and training
- Influenza and pneumococcal vaccination information and recommedations
- New behavioral health programs
- Montefiore Diamond Care MLTC Plan enrollment process
- EmblemHealth SNP's Model of Care
- Disease management classes for patients
- Provider Relations contacts
- Available office space
ICD-10 codes must be used to identify symptoms and conditions on all healthcare claims for dates of service beginning October 1, 2015. Claims submitted with the shorter ICD-9 codes will be denied.
Claims submitted for services authorized prior to September 30, 2015, but extending beyond that date, must be billed with ICD-10 codes for all dates of service beginning October 1, 2015.
Complete information and resources on the transition to ICD-10 codes, including an ICD-10 Quick Start guide are available from CMS on the following website: https://www.cms.gov/Medicare/Coding/ICD10/ProviderResources.html?gclid=CJWzqdTftccCFdgSgQodQysNbA
To help make the transition as easy as possible for both employed and voluntary providers, Montefiore has developed an online course—ICD-10 and the Provider—that is available on its Talent Management system.
Montefiore employees can access “ICD-10 and the Provider” in the Talent Management system by following these steps:
1. Access the system by clicking on the Talent Management and Learning icon (head with gears) on your desktop or visiting https://performancemanager4.successfactors.com/login?company=Montefiore through your web browser (Internet Explorer 8 or higher recommended).
2. Log in.
- Your Username will be all 6 digits of your EZ-Time number (located on the top of your pay stub).
- The first time you log in, your Password will be the same as your Username. You will then be prompted to change your password.
3. When you login, you will be on the Talent Management home page. It may take a moment for the page to load the first time. If you see ICD-10 and the Provider on your To Do list, you may access it from there.
4. If you do not do not see that prompt, find the drop-down menu in the upper left corner of the screen and select Learning.
5. Under Find Learning click in the box that says What do you want to LEARN today?
6. Type “ICD-10 and the Provider” in the box and click Go.
7. Hover your mouse over the course name: ICD-10 and the Provider
8. Click on Start Course. The course should open in a popup window.
Voluntary providers can access “ICD-10 and the Provider” on Montefiore’s Talent Management Learning system by following these steps:
1. Access the system by visiting https://montefiore.plateau.com/learning/user/portal.do?siteID=VOLUNTARY&landingPage=login (Internet Explorer 8 or higher recommended).
2. Log in.
- Your Username will be V + your NYS license number (e.g., V123456).
- The first time you log in, your Password will be “welcome1”. You will then be prompted to change your password.
3. It may take a moment for the homepage to load the first time. If you see ICD-10 and the Provider listed under My Learning Assignments, you may access it from there.
4. If you do not see that prompt, under Find Learning click in the box that says What do you want to LEARN today?
5. Type “ICD-10 and the Provider” in the box and click Go.
6. Hover your mouse over the course name: ICD-10 and the Provider.
7. Click on Start Course. The course should open in a popup window.
For technical assistance with the Talent Management Learning system, send an email to LearningNetwork@montefiore.org or call 718-920-8787.
Flu season is just around the corner, and immunization is recommended for all patients six months old and above, including pregnant women, and is especially important for all patients age 65 and older.
The flu vaccine should be offered during a patient visit as soon as your practice has a supply. This is also an opportunity to offer a pneumococcal immunization and to check the patient’s medical record to determine if other recommended immunizations, including tetanus and zoster, as well as preventive services, are indicated.
Medicare (Part B), Medicaid and most commercial insurers cover both the costs of the flu vaccine and its administration by recognized providers. There is no Medicare coinsurance or co-payment applied to this benefit, and a beneficiary does not have to meet his or her deductible to receive this benefit.
For 2015–16, U.S.-licensed trivalent influenza vaccines will contain hemagglutinin (HA) derived from an A/California/7/2009 (H1N1)-like virus, an A/Switzerland/9715293/2013 (H3N2)-like virus, and a B/Phuket/3073/2013-like (Yamagata lineage) virus. This represents changes in the influenza A (H3N2) virus and the influenza B virus as compared with the 2014–15 season. Quadrivalent influenza vaccines will contain these vaccine viruses, and a B/Brisbane/60/2008-like (Victoria lineage) virus, which is the same Victoria lineage virus recommended for quadrivalent formulations in 2013–14 and 2014–15 (8).
There are also influenza vaccines for patients with egg allergies (i.e. Flublok); a high dose vaccine recommended for patients over 65 years of age (i.e. Fluzone High-Dose); and both trivalent and quadrivalent influenza vaccine options for patients.
Additional information for clinicians about influenza and vaccination recommendations from the CDC is available at http://www.cdc.gov/flu/professionals/acip/index.htm.
Information about the flu appropriate for patients can be found on the following CDC web page: http://www.cdc.gov/flu/about/season/flu-season-2015-2016.htm.
Because health care workers are at increased risk for acquiring influenza infection and transmitting disease to their patients, colleagues and families, it is recommended that all health care workers should receive annual influenza vaccination, especially if they are in close contact with high-risk patients.
The pneumococcal immunization is strongly recommended for adults beginning at age 65. Pneumococcal vaccine coverage rates among New Yorkers aged 65 and older have been persistently below national goals.
Unlike the flu vaccine, which must be administered annually, one pneumococcal immunization at age 65 or older generally provides coverage for a lifetime. For some at high risk, however, vaccinations may need to start earlier and revaccination may be appropriate. The Advisory Committee on Immunization Practices (ACIP) has recommended routine use of 13-valent pneumococcal conjugate vaccine (PCV13 [Prevnar 13]) among adults aged 65 years and older. PCV13 should be administered in series with the 23-valent pneumococcal polysaccharide vaccine (PPSV23 [Pneumovax23]), the vaccine currently recommended for adults aged in that age group. PCV13 was approved by the FDA in late 2011 for use among adults aged ≥50 years. (For more information on these recommendations, see pages 822-825 at http://www.cdc.gov/mmwr/pdf/wk/mm6337.pdf )
The chart below shows the ACIP recommendations for the administration of pneumococcal vaccine to adults adults >65 years of age:
It is not necessary to ask patients to show their immunization record prior to administering the pneumococcal vaccines or to review the complete medical record if it is not available. For patients competent to make their own decisions, you may rely on the patient’s verbal history to determine prior pneumococcal vaccination status. If a patient older than 65 is uncertain about his or her vaccination history, administer the vaccine.
Medicare (Part B) provides coverage for one pneumococcal vaccine for all beneficiaries. There is no coinsurance or co-payment applied to this benefit, and a beneficiary does not have to meet his or her deductible to receive this benefit. Medicare will also cover a pneumococcal vaccine for persons at the highest risk if five years have passed since the last vaccination, but routine revaccinations of beneficiaries who are not at the highest risk are not appropriate.
If a patient younger than 65 is certain of being vaccinated within the last five years, do not administer the vaccine. If the patient is certain that more than five years have passed since receipt of the previous dose, administer the revaccination only if the patient is at highest risk (see list below).
Patients who should be considered for vaccination before they turn 65 include those with:
- Chronic lung disease (including asthma, COPD, and emphysema)
- Cardiovascular diseases
- Diabetes mellitus
- Chronic renal failure or nephrotic syndrome
- Chronic liver disease (including cirrhosis)
- Tobacco smokers
- Adults living in skilled nursing facilities or long term care facilities
- Functional or anatomic asplenia (e.g., from sickle cell disease or splenectomy)
- Human Immunodeficiency Virus (HIV)
- Immunocompromising conditions (e.g. malignancies; chemotherapy, long term corticosteroid use)
- Cochlear implants
- Cerebrospinal fluid leaks.
Highest risk patients under 65 who should be considered for pneumococcal revaccination five years after their first dose include those with:
- Chronic renal failure or nephrotic syndrome;
- Functional or anatomic asplenia (e.g. Sickle cell disease or splenectomy) Immunocompromising conditions
A chart with the CDC’s full recommended adult immunization schedule is available at: http://www.cdc.gov/vaccines/schedules/downloads/adult/adult-schedule.pdf
As part of New York State’s efforts to “achieve measurable improvement in health outcomes, sustainable cost control, and a more efficient administrative structure" in the Medicaid program, it is embarking on a far-reaching restructuring of the delivery of behavioral health services and their integration with medical care for Medicaid members beginning October 1, 2015.
All adult recipients who are eligible for Medicaid Managed Care (excluding Medicare recipients and certain other populations), will receive the full physical and behavioral health benefit through managed care. This means that a large number of behavioral health services previously “carved out” of the managed Medicaid benefit will now be the responsibility of managed care organizations (MCOs) to authorize and pay for. Such services were previously the sole responsibility of fee-for-service Medicaid and include: all outpatient Substance Use Disorder (SUD) treatment, including methadone maintenance programs; psychiatric Partial Hospitalization Programs; Personalized Recovery Oriented Services (PROS); Assertive Community Treatment (ACT) teams, and more.
Also effective October 1, 2015, consumers enrolled in a Medicaid managed care plan (MMC) whose behavioral health benefit was covered under Fee for Service Medicaid through SSI will begin receiving these benefits through the MMC plan.
In addition, the State has created a special, separate comprehensive package for select Medicaid recipients, a “plan within a plan” called Health and Recovery Plans (HARP). Adults enrolled in Medicaid and 21 years or older with select Serious Mental Illness (SMI) and Substance Use Disorder (SUD) diagnoses having serious behavioral health issues will be eligible to enroll in this new type of health plan. HARPs will arrange for access to a benefit package of Home and Community Based Services (HCBS) for members who are determined eligible. HARPs will contract with Health Homes, or other State-designated entities, to develop a person-centered care plan and provide care management for all services within the care plan, including the HCBS.
These changes will be rolled out as follows:
- October 1, 2015: MMC plans and HARPs implement expansion of non-HCBS behavioral health services for enrolled members
- October 2015-January 2016: HARP enrollment begins to phase in
- January 1, 2016: HCBS become available for HARP eligible individuals
For primary care providers and other non-behavioral specialists, a fundamental component of the changes are many requirements designed to address the severe gap in effective medical care of people with Serious Mental Illness (SMI). Such individuals die on average many years earlier than those without SMI, with some estimates placing the discrepancy at as much as 15-25 years. Quality measures will target annual metabolic screenings for individuals on anti-psychotic medications, and managed care organizations (MCOs) will be responsible for ensuring follow up of medical findings and recommendations made during behavioral health admissions. MCOs will be expected to foster and ensure enhanced communication and coordination between primary care providers and behavioral health specialists.
More information pertaining to these changes and their impact on daily operational practices will be forthcoming from various sources in the coming months. If you have any questions in the meantime, please address them to UBAMBCIPA@montefiore.org.
Greater detail about the new Medicaid landscape can be found on the following websites:
- NYS Office of Mental Health (OMH): http://www.omh.ny.gov/omhweb/bho/
- Managed Care Technical Assistance Center (MCTAC): http://mctac.org/page/get-the-right-tools/resources/
Montefiore Diamond Care is a Managed Long Term Care health plan designed for Medicaid (or Medicaid/Medicare dually eligible) beneficiaries who need more than 120 days of long-term care services, but who would rather live independently at home.
Members of Montefiore Diamond Care must be at least 21 years old, Medicaid-eligible, reside in the Bronx or Westchester and have health problems or limitations that require long-term care services for more than 120 days. These services include home health aides, skilled nursing facility admissions, adult and social day care, podiatry, audiology, PT/OT/SP, dental and vision care, home-delivered meals and environmental supports.
Enrolling in Montefiore Diamond Care won’t change the way members currently receive medical care or prescription drug coverage. Members can continue to see the doctors and other medical professionals they do now. The Montefiore Diamond Care team will work with you and your patient to help coordinate both their MLTC and medical appointments.
To refer a potential member to Montefiore Diamond Care, you can connect your patient with the Conflict-Free Evaluation and Enrollment Center (CFEEC) at 1-855-222-8350.
An independent CFEEC evaluation is required by New York State for all potential members needing long-term care services for the first time. After connecting your patient with the CFEEC, send a brief email to us at CMOMLTCReferrals@montefiore.org with the patient’s name, phone number and Medicaid ID (or DOB if no Medicaid ID is available) so we can track the referral status and patient’s progress towards becoming a member.
If your patient is already receiving long-term care services and is interested in joining Montefiore Diamond Care, you can make a referral by calling 1-855-55-MONTE (press option 2).
CMO has established a SNP Model of Care with the following six goals to provide an appropriate level of care for members of EmblemHealth’s Dual Eligible Special Needs Plan (SNP), for which the CMO has care management responsibility:
- Access to medical, mental health, social services, affordable care and preventive health services
- Coordinated care through an identified point of contact
- Transition of care across health care settings and practitioners
- Appropriate services
- Cost-effective service
- Beneficiary health outcomes
CMO Network Care Management staff support each of these goals through the application of its Utilization Management, Complex Case Management and Care Transitions Programs. EmblemHealth conducts periodic Health Risk Assessments (HRAs) and sends the results to the CMO. CMO then screens the member for the appropriate program referral and intervention. On a monthly basis, the CMO also reviews claims data to identify any SNP members who might be eligible for the CMO Complex Case Management Program and then contacts the member’s PCP and Interdisciplinary Care Team to assist in the development of the care plan.
CMO Network Care Management staff will also monitor the transition of any SNP Dual Eligible members who go from one care setting to another, regardless of whether or not the transition was planned, and will assist with the coordination of care and the communication of the Individualized Care Plan with the PCP and the Interdisciplinary Care Team, as appropriate. EmblemHealth uses specific HEDIS, QARR and CAHPS measures to evaluate the effectiveness of the care SNP members receive. The CMO shares all data related to outcomes measures with EmblemHealth and will know if we have met our goals to improve the health outcomes for this membership by assessing the following outcomes:
- Reduction in A1C
- Member satisfaction
- Maintain low rate of unplanned admissions
- Timeliness of care transition notification of the receiving care setting from the sending setting
Provider education is an integral part of the SNP Model of Care. For more information, you can find EmblemHealth’s SNP Model of Care Training Presentation at:
If you need assistance with any of your patients who are EmblemHealth SNP members, call the CMO, Network Care Management Department at 914-378-6722 or Kathleen Byrne, RN, MPH, Senior Director, Network Care Management at 914-377-4762.
CMO offers free diabetes, respiratory (asthma/COPD) and chronic kidney disease workshops. Patients, their family members and caregivers are welcome to attend. Registration is not required. Diabetes and respiratory workshops are available in English and Spanish. Click here to view workshops schedules.
For general questions about your participation please contact the Provider Relations main line, at 914-377-4477.
Director of Provider Relations
Provider Relations Liaison
Voluntary & Non-MMC Non-Montefiore-Affiliated-Physicians – Bronx
Provider Relations Liaison
Montefiore-Affiliated Westchester Physicians
Provider Relations Liaison
Montefiore Medical Group Physicians
Provider Relations Liaison
Voluntary & Non-Montefiore-Affiliated-Physicians – Westchester Vendor Services
Provider Relations Liaison
Electronic Data Interchange (EDI) Specialist & Post N Track Coordinator
Provider Relations Liaison
Montefiore-Employed/Faculty Practice Physicians & Montefiore HMO (MLTC)
Dobbs Ferry: 18 Ashford Avenue – Fully furnished medical space in medical office building. Includes two treatment rooms and a consultation room. Available for three-to four-day practice schedule. Specialist welcomed. Call Sanford Proner, MD, at 914-772-7595.
Bronx: 3584 Jerome Ave. (off of 213th St.)—2700 sq. ft., modern, 4 exam rooms, reception area, and a consultation office. Metered parking available. Flexible hours. Call Meir Salama, MD, at 718-231-4443.
Riverdale: Share a large medical office conveniently located near public transportation and major highways. Rent includes two examining rooms, furnishings and office assistance. Flexible hours are available. Call Robin Schiff, MD, at 718-549-6229.
Riverdale: Riverdale Ave./Corner of 235th St.—three exam rooms for specialist in primary care office. Each room is 110 sq. ft. and furnished. Shares a beautiful, spacious waiting room. Call Liliya Lotsvin, MD, at 718-432-5500.
Riverdale: 5750 Mosholu Avenue—Four rooms available for rent for any medical specialties. Professional space for medical specialist – GYN or neurologist. Current full-time opening for Internal Medicine physician. Call 718-601-0627- or 718-601-0628.