Delaware | Winter 2013 ratieatter...Delaware | Winter 2013 For More Information Call our Provider...
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Community Plan practice matters Delaware | Winter 2013 For More Information Call our Provider Services Center at 800-600-9007 Visit UHCCommunityPlan.com
Transcript of Delaware | Winter 2013 ratieatter...Delaware | Winter 2013 For More Information Call our Provider...
Community Plan
practicemattersDelaware | Winter 2013
For More Information
Call our Provider Services Center at 800-600-9007Visit UHCCommunityPlan.com
Community Plan
Practice Matters: DE - Winter 2013
Important information for health care professionals and facilities
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Provider Services Center: 800-600-9007
In This Issue...
Front & Center• AMessageFromOurChiefMedicalOfficer,Dr.GregoryBusch,DO
• ActionNeeded:TransitiontoNewEnrollmentandClaimsSystem
Plan Changes and UPdates• New Address for Provider Disputes and Appeals
lIve and Work Well resoUrCes noW avaIlable to MeMbers
• NewPocketGuideAvailable:The Guide for Clinical Preventive Services: Recommendations of the U.S. Preventive Services Task Force
• WeareListening:HighlightsFromPhysicianAdvisoryCommittee
• ResultsFromOur2013AnnualMemberSatisfactionSurvey
• SpotlightonUnitedHealthcareCommunityPlanCaseManagement and Care Coordinators
• EnhancedHIPAAEditstobeAppliedtoClaimSubmissions
IMPortant reMInders• All Providers Must Have a Current Disclosure of
Ownership and Control Interest Statement on File
• Reminder:TimelyFilingofClaims
• Reminder: Corrected Claim Process
• MeetingOurMembers’CulturalNeeds
• Timeframes for Provider Appointments
UnItedhealthCare CoMMUnIty Plan oF delaWare ContaCt InForMatIon
Practice Matters: TX - Summer 2013 Customer Service Center: 888-362-33681
Community Plan
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Important information for health care professionals and facilities
Practice Matters: DE - Winter 2013 Provider Services Center: 800-600-9007
Front & Center
A Message From Our Chief Medical Officer,GregoryBusch,DOUnitedHealthcare Community Plan of Delaware Receives Commendable NCQA Rating
We are pleased to announce that UnitedHealthcare CommunityPlanofDelaware’sDiamondStateHealthPlanhasearnedNationalCommitteeforQualityAssurance (NCQA) accreditation and received its Commendable rating. NCQA awards Commendable statustoorganizationswithwell-establishedprogramsforserviceandclinicalqualitythatmeetrigorousrequirementsforconsumerprotectionandqualityimprovement.Thisaccreditationwouldnothavebeenpossiblewithoutthepartnershipweenjoywithourparticipating providers as we work together to help memberslivehealthierlives.
NCQAPresidentMargaretE.O’Kanesaid,“AchievinganaccreditationstatusofCommendableisasignthatahealthplanisseriousaboutquality.ItisonlyawardedtoplanswhoseserviceandclinicalqualitymeetorexceedNCQA’srigorousrequirementsforconsumerprotectionandqualityimprovement.”
NCQAaccreditationrequireshealthplanstosubmitauditeddataonkeyclinicalandservicemeasures.Itprovidesmembersandpotentialmemberswiththeabilitytoevaluatethequalityofdifferenthealthplansalongavarietyofimportantdimensionsandmakehealthplandecisionsbasedondemonstratedvalue.
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Again,pleaseknowthatweappreciatetheimportant roleyouplayinthisachievementandoursharedcommitmenttoquality.
Action Needed: Transition to New EnrollmentandClaimsSystemUnitedHealthcareCommunityPlanofDelawarewilltransitiontoanewenrollmentandclaimssystemonMarch1,2014.
Action RequiredWith the transition, your Payer Id for electronic claims submissions will change. It is very important to contact your billing, software or clearinghouse vendor immediately so they can assist you with making the necessary changes to your practice’s billing system by March 1, 2014. For those claims with a date of service prior to March 1, 2014, you will need to continue to use your existing Payer Ids, and you are encouraged to submit those claims as soon as possible.
Members’healthcarebenefitswillnotchangeandyourUnitedHealthcareCommunityPlanpatientsdonotneedtotakeanyactiontokeeptheircoverageoryouas theirphysician.
Highlights of the enrollment and claims system changes include:
• PayerIDchangeswithelectronicclaimssubmissions(ACTIONNEEDED–seeabove).
• TheClaimsPayerIDwillchangeto87726.
• Realtimeclaimsstatusandeligibilitytransaction PayerIDwillchangeto87726.
• Electronicremittanceadvice(ERA)PayerIDwillchangeto04567.
• Streamlined remittance advice for dates of service occurring after the transition.
Practice Matters: TX - Summer 2013 Customer Service Center: 888-362-33682
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Important information for health care professionals and facilities
Practice Matters: DE - Winter 2013 Provider Services Center: 800-600-9007
• Clearerexplanationcodesandenhancedsummaryofoverpayments/paymentsrecovered.
• PhysicianswhoarecurrentlyreceivingERAfor Delaware will continue to receive ERA throughtheircurrentconnectivity.IfyouwouldliketostartreceivinganERA,pleasecontactyoursoftwarevendororclearinghouseandhavethemenrollyouthroughourpartner,OptumInsight.
• Long Term Care Facilities and Assisted Living Facilities ONLY: Your remittance advice currentlyshowsthepatientliability,ifapplicable,intheCOBadjustmentfieldwithanexplanationcodeof108:“adjustmentduetoclaimrecalculation.”Thenewremittanceadvicelayoutwillshowpatientliabilityintheco-insuranceamountwithanexplanationcodeof142:“monthlyMedicaidpatientliabilityamount.”
• NewmemberIDcardswithnewmemberIDnumbers.
• AswitchfromUHCCommunityPlan.comtoUnitedHealthcareOnline.comforonlinemembereligibilityandclaimstransactions.
• Fordatesofservicepriortothetransition,pleasecontinue to useUHCCommunityPlan.com. For datesofserviceonorafterthetransition,pleaseuse UnitedHealthcareOnline.com. Look for upcoming training invitations.
• Changes to prior authorization rules effective for datesofserviceonandafterMarch1,2014.
• Priorauthorizationchangeswillbeupdatedinthe provider administrative guide. Providers will notneedtoresubmitanypreviouslysubmittedauthorizations for dates of service on or after March1,2014.HCBSproviderswillnotbeimpactedbythepriorauthorizationchanges.
• Provider Services interactive voice response (IVR) phonenumberchange.
• Pleasecall800-600-9007formembereligibilityor to check claim status.
• Anesthesiareimbursement.
• EffectiveMarch1,2014,partialtimeunitswillbeproratedandcalculatedtoonedecimalplaceroundedtothenearesttenth.Forexample,iftheanesthesiatimeunitvalueisbasedon15minutesand28minutesofactualtimeissubmittedontheclaim,thenthe28minuteswillbedividedby15.Theresultingfigureof1.866willberoundedtothenearesttenthandthetotaltimeunitsfortheclaimwillbe1.9timeunits.Previously,UnitedHealthcareCommunityPlanrounded up or down to the nearest whole unit.
Ifyouhaveanyquestionsaboutthetransition,pleasecontactyourProviderAdvocateorcallProvider Services at 800-600-9007.
Plan Changes and UPdates
NewAddressforSubmittingProvider AppealsWe have changed our mailing address for grievances and appeals. Please mail appeals to:
UnitedHealthcareCommunityPlanAttn:GrievanceandAppealsDepartmentP.O.Box31364SaltLakeCity,UT84131-0364
Pleasebesuretoincludethefollowingwithyour appeal request:
• Member’snameandplanIDnumber.• Claimnumberandacopyoftheclaimorcopyof
remittance advice.• Adetaileddescriptionofyourdispute(e.g.,state
thecodeandissuefordisputesoveraspecificprocedure code).
• Anydocumentationyoucanprovideinsupportofyourdispute.
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Practice Matters: TX - Summer 2013 Customer Service Center: 888-362-33683
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Important information for health care professionals and facilities
Practice Matters: DE - Winter 2013 Provider Services Center: 800-600-9007
• Aname,phonenumberandmailingaddresstocontactyourofficeifneeded(thisshouldbetheaddresswhereyourresponseshouldbemailed).
• Medicalrecords,ifapplicable.
lIve and Work Well resoUrCes noW avaIlable to MeMbers Wewantourmemberstolivehealthierlivessowe’reputtinghealthandwell-beinginformationattheirfingertips.MemberscansimplyvisittheUnitedHealthcareCommunityPlanpage;selectLinks to Health Information and then Live and Work Welltoaccessarticlesaboutparenting,relationships,safety,careers,education,mentalhealthandsubstanceabuse.
NewPocketGuideAvailable: The Guide for Clinical Preventive Services: Recommendations of the U.S. Preventive Services Task ForceLookingforup-to-dateinformationaboutpreventiveservices? The Guide for Clinical Preventive Services’ new pocket guide includes U.S. Preventive Services TaskForcerecommendationsonscreening,counselingand preventive medication topics and includes clinical considerationsforeachtopic.It’sagoodresourcefor
generalpractitioners,internists,familypractitioners,pediatricians,nursesandnursepractitionerswithanauthoritativesourceformakingdecisionsaboutpreventive services.
Foracopyoftheguide,pleasevisit:http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/guide/index.html.
We Are Listening: PhysicianAdvisoryCommittee Meetings UnitedHealthcareCommunityPlan of Delaware hosts quarterlyPhysicianAdvisoryCommittee (PAC) meetings tohelpidentifyandaddressissues,aswellassolicitfeedbackonbusinesspracticesandqualityimprovement.Thegroup consists of a wide range ofphysicians,includingadultprimarycare,behavioralhealth,medicalspecialistsandpediatricians.Beneficialsuggestions,liketheadditionofamobilephlebotomyunit,arearesultofthesesessions.HighlightsfromupcomingPACmeetingswillbefeaturedin future issues of Practice Matters.
Results From Our 2013 Annual MemberSatisfactionSurveyAreIn!UnitedHealthcareCommunityPlancontinuouslystrivestoimprovethecareandservicesprovidedtoourmembers.Animportantmeasureofsuccessinexceedingmembersatisfaction is our annual Consumer Assessment of HealthcareProvidersandSystems(CAHPS)survey.
SurveysweremailedtomembersbetweenFebruaryandMay2013.MemberswereaskedtoreportontheirexperiencewithUnitedHealthcareCommunityPlanduring
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Practice Matters: TX - Summer 2013 Customer Service Center: 888-362-33684
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Important information for health care professionals and facilities
Practice Matters: DE - Winter 2013 Provider Services Center: 800-600-9007
theprevioussixmonths.Some of the questions inthesurveyaskedhowhappymemberswerewiththeirpersonaldoctors,thespecialiststheyvisitmostoften and their access to care and customer service.
Ingeneral,memberswereverysatisfiedwiththeirdoctorsandspecialists,our health plan and their health care.
Oneareaofopportunityourmembersidentifiedisthecomfortleveltheyfeelcommunicatingwiththeirdoctors,particularlyfortheiryoungchildren.Welistenedtoourmembers’feedbackandareworkingtoenhanceourprograms and communication in this area. We applaud all of our providers for their efforts in working with our membersandemphasisonpatient-centeredcare.
ThenextCAHPSsurveywillbegininearly2014.Wewillbecarefullyreviewingtheresultsaswe’realwayslookingto improve.
Ifyouwouldlikeadditionalinformation abouttheCAHPSsurveyorourQualityImprovementProgram,pleasecallProviderServices at 800-600-9007.
Spotlight on UnitedHealthcare CommunityPlanCaseManagementand Care CoordinatorsCare coordinators are an important part ofUnitedHealthcareCommunityPlan.They:
• Managetheservicesthatalllongtermcaremembersreceivetomeettheirphysicalhealth,mentalhealthand long term care needs.
• Develop individual service plans for assigned membersandcommunicatethemtomembers’PCPs.
• Ensurethereisgoodcommunicationbetweenmembers’specialistsandPCPs.
• Calltheirassignedmembersmonthly.• Conductface-to-facevisitsatleasteverythree
monthsforhome-andcommunity-basedmembersandeverysixmonthsformembersinnursinghomes.
UnitedHealthcareCommunityPlanalsoprovidescasemanagementservicestomemberswithspecialneeds,suchasphysicaldisabilities,seriousmentalissuesandcomplexhealthproblems.Casemanagersworkwiththeplan,memberphysiciansandoutsideagenciestohelpmembersgetthespecialservicesandcaretheyneed.
Additionally,UnitedHealthcareCommunityPlanoffersdisease management programsfordiabetes,heartdisease,asthma,HIV,chronicobstructivepulmonarydisease,hypertensionandhighriskpregnancy.Membersintheseprograms receive reminders abouttheircareandadvicefrom a nurse.
ToreferamemberforCaseManagementorDiseaseManagement,call877-877-8159.
EnhancedHIPAAEditstobeAppliedtoClaimSubmissionsEffectiveMarch5,2014,UnitedHealthcarewillapplyanenhancedlevelofHealthInsurancePortabilityandAccountabilityAct(HIPAA)editstoprofessional(837p)andinstitutional(837i)claimssubmittedelectronically tomostUnitedHealthcareandaffiliatePayerIDs.*
Becausetheneweditswillbeappliedona pre-adjudicationbasis,anincreaseinthenumber ofclaimrejectionsmayoccur.Thiswillenableyouto identifyandcorrectrejectedinformationpriortothe
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Practice Matters: TX - Summer 2013 Customer Service Center: 888-362-33685
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Important information for health care professionals and facilities
Practice Matters: DE - Winter 2013 Provider Services Center: 800-600-9007
claim’sacceptanceintoouradjudicationsystemforprocessing.Thebenefitwillbefewerdeniedclaims and less interruption to revenue streams.
Theprimaryimpacttoyouwillcomefromneweditsthatwillvalidatecodesets(suchasdiagnosis,procedure,modifierandnationaldrugcodes)atapre-adjudicationlevel. View a complete list of enhanced edits.
It’simportanttocheckallofyourclaimsubmissionreportsregularly.ClaimsmayberejectedbyyourclearinghouseorUnitedHealthcare;therefore,youmayreceivemultiplereportspersubmission.
Ifyouhaveanyquestionsaboutthesechanges,pleasecontactyourclearinghouse/softwarevendororourElectronic Data Interchange (EDI) Support:
*Exceptions:HarvardPilgrim(04271),MedicaHealthCarePlans(78857),Preferred CarePartners(65088),theAlliance(88461)andTRICAREWest(99726)
IMPortant reMInders
All Providers Must Have a Current Disclosure of Ownership and Control Interest Statement on File AllUnitedHealthcareCommunityPlannetworkprovidersmusthaveacurrent,up-to-dateDisclosureofOwnershipandControlInterestStatementonfilewiththeDelaware
Division of Medicaid and Medical Assistance. The state mustmonitorpaymentsofMedicaidfundstoprovidersthroughthesestatements.Ifyoudonothaveadisclosureonfile,yourclaimscouldbedeniedforpayment.
Theformandinstructionsareavailableforcompletion at https://www.dmap.state.de.us/secure/logon.do.Ifyouhavequestions,pleasecontactHPProviderServicesat1-800-999-3371,option0,option2.
Reminder:TimelyFilingofClaimsToensuretimelyclaimsfilings,newclaimsmustbesubmittedwithin90daysfromthedateofservice.IfUnitedHealthcareCommunityPlanisnottheprimarypayer,youhave180daysfromthedateofservicetosubmitaclaim.Wewillforwardaremittanceadviceandreimbursement(contingentuponproperauthorizationandmembereligibility)within30daysfromreceiptofaclaim.
Reminder: Corrected Claim ProcessIfyoureceiveadenialandneedtosubmitacorrectedclaimtoUnitedHealthcareCommunityPlan,youmaydosowithin45daysofreceivingourremittanceadvice.Please correct the claim according to the corrected claims policyinyourProviderManual.ViewtheProviderManualat UHCCommunityPlan.com > Manuals and Forms.
MeetingOurMembers’ Cultural NeedsUnitedHealthcareCommunityPlanmembershavetherighttoreceiveculturallycompetentcarewhichrespectstheirculturalandethnicbackgroundandorigins.PrimarylanguageinformationisobtainedfrommemberswhentheyenrollandtheyareassistedinchoosingaPCPwhowillmeettheirculturalneeds.TheProviderDirectoryisavailableatUHCCommunityPlan.com and lists languagefluency.
UnitedHealthcare Commercial
EDI issue reporting form or800-842-1109
UnitedHealthcare CommunityPlan
[email protected] or800-210-8315
UnitedHealthcare Medicare Solutions
EDI issue reporting form or800-842-1109
UnitedHealthcare West
EDI issue reporting form or800-842-1109
UnitedHealthcare Oxford
[email protected] or800-599-4334
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Practice Matters: TX - Summer 2013 Customer Service Center: 888-362-33686
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Important information for health care professionals and facilities
Practice Matters: DE - Winter 2013 Provider Services Center: 800-600-9007
We have a language line for translation of communication betweenourstaffandnon-Englishspeakingmembers.Usageistrackedandreportedregularlytothehealthplan.Withthisinformation,thehealthplanassessespractitioneravailabilitytoensurethatmembers’cultural,ethnic,racialandlinguisticneedsaremet.
Timeframes for Provider AppointmentsTimelyaccessisessentialtothedeliveryofqualityhealthcare.Ifadelayincareoccurs,patientswitharoutine,symptomaticillnessmayendupseekingcareinahospitalemergencyroom.UnitedHealthcareCommunityPlan follows set standards for its network of providers that encouragestimelyaccessinschedulingappointmentsand patient evaluation. These standards are developed andapprovedbyourqualityimprovement/utilizationmanagementcommittee.Pleasereviewyourappointmentpracticestoensureyoumeettheserequirements:
Primary Care Provider appointments • Emergency:Thesamedayorreferredtoan
emergencyfacility.• Urgent:Withintwocalendardays.• Routine: Within three weeks of request.• EarlyPeriodicScreening,Diagnosis,andTreatment/
Child Preventive Care: Within two weeks of request.
specialist appointments • Emergency:Immediatelyuponreferral.• Urgent:Within48hoursofreferral.• Routine: Within three weeks of referral.
obstetrics appointments • First trimester: Within three weeks of request.• Secondtrimester:Withinsevencalendardays
of request.
• Thirdtrimester:Withinthreecalendardaysofrequest.• Highrisk:Withinthreecalendardaysofidentification
ashighriskorimmediatelyifanemergencyexists.
behavioral health Care Provider appointments • Life-threateningemergency:Immediatelyorreferred
toanemergencyfacility.• Non-life-threateningemergency:Serviceswithinsix
hours of request.• Urgent:Within48hours.• Routine:Withinsevencalendardaysofrequest.
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Practice Matters: TX - Summer 2013 Customer Service Center: 888-362-33687
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Important information for health care professionals and facilities
Practice Matters: DE - Winter 2013 Provider Services Center: 800-600-9007
long term Care Management team
DebbyPecoraro,RNNewCastleCountyPhone: [email protected]
TemikaCarter,RN,BSNNewCastleCountyPhone:[email protected]
KristenFranklin,RNKent/SussexCountiesPhone:[email protected]
PattyWinward,RNKent/SussexCountiesPhone:[email protected]
Member advocates EricaKearseMedicaid and Delaware HealthyChildrenProgramPhone: [email protected]
TracySpragueDiamond State Health Plan Plus (DSHP-Plus)Phone:[email protected]
Quality Management department
Desiree DowlingSr.QualityAnalystPhone: [email protected]
Christine PuckettHealth EducatorPhone: [email protected]
PaulFransisco,RNClinicalQualityAnalystPhone:[email protected]
UnItedhealthCare CoMMUnIty Plan oF delaWare ContaCt InForMatIon
Unitedhealthcare Community Plan Website
UHCCommunityPlan.com
Provider Call Center 800-600-9007Monday-Friday, 8a.m.to5p.m.
general Mailing address
UnitedHealthcare CommunityPlan4051OgletownRoad, Suite 200Newark,DE19713
Claims Mailing address
UnitedHealthcare CommunityPlanP.O.Box8207Kingston,NY12402
Utilization Management and Claims appeals address
UnitedHealthcare CommunityPlanP.O.Box31364SaltLakeCity,UT 84131-0364
behavioral health Providers
For inquiries related to credentialing,demographicupdates or adding a new providertoyourpractice,please contact OptumHealth (UnitedBehavioralHealth)at877-614-0484.
Member eligibility via Interactive voice response line
888-586-4766
skilled service Providers Credentialing
877-842-3210
non-skilled service Providers
800-600-9007
4051 Ogletown RoadSuite 200Iron Hill Corporate CenterNewark, DE 19713UHC2788c_20131205 © 2013 UnitedHealth Group, Inc. All Rights Reserved.
Practice Matters is a quarterly publication for physicians and other health care professionals and facilities in the UnitedHealthcare network.
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