CurrentAspirus ArisePolicy N/A

Disease Management Programs — Diabetes and Heart Failure Health Coaching

Defines Aspirus Health Plan's Disease Management high-risk health journey programs providing telephonic health coaching and monitoring tools for eligible members with recent diabetes or heart failure events; describes eligibility, exclusions, and referral process for members and PCP communication.

Policy Summary

PayerAspirus Arise

PolicyDisease Management Programs — Diabetes and Heart Failure Health Coaching

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit referrals using the Aspirus Health Plan referral form or call the Disease Management Line to enroll eligible members.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

65-75age range eligible

15 monthsrecency window

2contact lines

LTC/hospice/dialysis/ESRDexclusions

Coverage Criteria — Disease Management Programs

Diabetes — High-Risk Health Journey Eligibility

Covered when ALL of the following are met:

Diabetes Eligibility: Member is age 65-75

Diabetes Eligibility: Member has a diabetes diagnosis in the previous 15 months15 months

Diabetes clinical/referal events

Acute utilization: At least one inpatient or emergency room event for diabetes within the last 15 months15 months

Policy Summary

PayerAspirus Arise

PolicyDisease Management Programs — Diabetes and Heart Failure Health Coaching

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit referrals using the Aspirus Health Plan referral form or call the Disease Management Line to enroll eligible members.

SourceLink

On This Page

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Heart Failure — High-Risk Health Journey Eligibility

Covered when ALL of the following are met:

Heart Failure Eligibility: Member is age 65-75

Heart Failure Eligibility: At least one heart failure inpatient or emergency room event within the last 15 months15 months

Heart Failure Eligibility: Member must be weight bearing

Clinical considerations: Current heart failure symptoms cause no limitation or only slight limitation of physical activity

Program note: The program provides telephonic health coaching and monitoring tools; the member's primary care provider receives an enrollment letter and condition updates as indicated.

Enrollment, Referral, and Provider Communication

Denial Risk

Exclusion Triggers

Members in Long Term Care/Skilled Nursing facilities, those on hospice or dialysis, or members with a diagnosis of End Stage Renal Disease (ESRD) are excluded from the Aspirus Health Plan Disease Management Programs (including Diabetes and Heart Failure health coaching).

Documentation Required

Referral and Communication Documentation

Providers should submit referrals using the Aspirus Health Plan referral form or by calling the Disease Management Line. Enrollment notifications and updates are sent to the member's primary care provider as indicated.

Referral form available on the Aspirus Health Plan website
Disease Management Line: 715-631-7443 or 1-855-931-5265
Monthly Disease Management Report used for referrals

Program Background

Aspirus Health Plan’s High-Risk Health Journey programs provide telephonic health coaching and, when needed, provision of monitoring tools for members identified as high risk following recent diabetes- or heart failure–related events. The Diabetes program targets members ages 65–75 with a diabetes diagnosis and at least one inpatient or emergency department event for diabetes within the prior 15 months, or members who self-refer or are referred and would benefit from coaching. The Heart Failure program targets members ages 65–75 who have had at least one heart failure inpatient or emergency department event within the prior 15 months and who are weight bearing; clinical considerations include members with no or slight limitation of physical activity. For both programs, the member’s primary care provider receives an enrollment letter and condition updates as indicated. Referrals are submitted via the monthly Disease Management Report, the web referral form on the Aspirus Health Plan website, or by calling the Disease Management Line.

Program Definitions

Health Coaching Program — definition and services

Program nameHigh-Risk Health Journey - Health Coaching

Primary services providedTelephonic health coaching and provision of tools to monitor condition as needed

PCP communicationPrimary Care Provider receives an enrollment letter and updates on member's condition as indicated

Eligibility contextProvided to members who meet program eligibility criteria (see Diabetes and Heart Failure eligibility rules)

Referral sourcesMembers referred via monthly Disease Management Report or by referral; referral form on Aspirus Health Plan website or Disease Management Line phone numbers

OpenPayer

Disease Management Programs — Diabetes and Heart Failure Health Coaching

Coverage Criteria — Disease Management Programs

Clinical Lookback and Coding Notes

Enrollment, Referral, and Provider Communication

Program Background

Program Definitions