Viral Load Suppression Tip Sheet Form

Document provided courtesy of Fidelis Care V23.0 3/1/2023

Information – Viral Load Suppression HEDIS defines the viral load suppression as the percentage of Medicaid enrollees confirmed to be HIV-positive who had an HIV viral load result of less than 200 copies/mL at the last HIV-viral-load test during the measurement year.

Diagnosis Guidelines Fidelis Care endorses HIV/AIDS treatment recommendations made by the New York State Department of Health AIDS Institute and the U.S. Department of Health and Human Services’ Office of HIV/AIDS and Infectious Disease Policy.

Effective Management Practice and Protocol  The New York State Department of Health AIDS Institute’s Clinical Guidelines, Standards, and Quality of Care resources are available at health.ny.gov/diseases/aids/providers/standards/index.htm.  The U.S. Department of Health and Human Services’ Office of HIV/AIDS and Infectious Disease Policy publishes policy resources at hhs.gov/ohaidp/resources/index.html.  Fidelis Care offers case management services to members with HIV/AIDS. For information about how to refer your patients, please call 1-800-247-1441 or email triage@fideliscare.org.

Billing and Reporting Practices Claim encounter data/valid Current Procedural Terminology (CPT) codes 87534 — 87539 Valid Logical Observation Identifiers Names and Codes (LOINC): 10351-5, 20447-9, 21008-8, 21333-0, 23876-6, 24013-5, 25835-0, 25836-8, 29539-4, 29541-0, 41513-3, 41514-1, 41515-8, 41516-6, 48510-2, 48511-0, 48551-6, 48552-4, 49890-7, 5017-9, 51780-5, 59419-2, 62469-2, 69353-1, 69354-9, 70241-5

Pharmacy Services  Beginning 4/1/2023, Fidelis Care members will have their pharmacy benefits transitioned to New York Medicaid Pharmacy Program (NYRx) provided by Magellan. For clinical concerns or Preferred Drug Program (PDP) questions, including Prior Authorization resources, please call Magellan at 877-309-9493 or visit https://newyork.fhsc.com/.
 Fidelis Care executes a multidisciplinary approach to case management services for members living with HIV. A team of HIV pharmacy experts routinely reviews member profiles, with a specific focus on members who are not virologically suppressed or have not had a viral load drawn in the last 12 months. After a thorough analysis, potential interventions by the HIV pharmacy expert may include but are not limited to:
o Working directly with providers to ensure the member is taking an appropriate, guideline-based regimen o Alerting the provider to potential drug interactions or therapeutic duplication with other medications o Referring the member to an HIV specialist provider when warranted
o Enrolling the member with case managers, who work with the member directly to access a myriad of Fidelis Care support services that can get them back into care and virologically suppressed

Fidelis Care is committed to ensuring quality care for members and adhering to HEDIS standards and policies.
Please visit fideliscare.org for educational resources and other helpful tools. Questions? Contact the Provider
Call Center at 1-888-FIDELIS (1-888-343-3547) and follow the prompts. Viral Load Suppression Tip Sheet