Provider Connection...Provider Connection We are proud to announce the Unison Health Plan of...

Provider Connection

We are proud to announce the UnisonHealth Plan of Pennsylvania 2009 GoldStar award winners. This year we have104 practices with 767 practitionerswho provide excellent primary healthcare to 69,641 Unison members.

There is one Gold Star practice withoutstanding performance in all qualitymeasures and extraordinary perform-ance in one area. This group providesall of the components recommended inthe Bright Futures/American Academyof Pediatrics guideline for 98 percent ofthe EPSDT-eligible Unison members as-signed to the practice.

Several weeks ago I visited this practice.My mission was to see what it wasabout the practice that produced such aremarkable result. When I arrived at thesite I found a leader; defined by AlanKeith as “someone who creates a wayfor people to contribute to makingsomething extraordinary happen”. Theleader empowered an EPSDT championwho coached, taught, facilitated and en-abled the team to participate in a sys-tem. The team members were engagedand accomplished the extraordinary. A98 percent EPSDT completion rate isamazing.

I found the heart of Gold Star. Thanksto all of the teams in all of the Gold Starpractices for doing the extraordinary.We at Unison are honored to be associ-ated with you.

A Provider Newsletter from Unison Health Plan of Pennsylvania SPRING 2009

� 2009 Gold Star Awards Announced!� Congratulations to our 2009 Gold Star Providers� Medicare Reminder: Notice of Medicare

Non-Coverage (NOMNC)� Pending Change to UM Guidelines� Medicare Payments for Physician Assistants� Taking Control of Allergic Rhinitis� We’re Online� HEDIS® Measures� Unison Practice Guidelines� Unison Formulary Update� Provider Spotlight� Improving Quality is Key� New Technology and Treatments� Help Stop Insurance Fraud� Blood Lead Screening & Young Children

on Medicaid� Provider Relations Team� Reportable Diseases Reminder

IN THIS ISSUE:

2009 Gold Star Awards Announced!

Gold Star 1

Joseph Sheridan, D.O.Medical Director,

Unison Health Plan of Pennsylvania

Unison MedPLUS � Unison Kids � Unison aB � Unison Advantage

CDC IMMUNIZATIONSCHEDULES

are posted on our web site

www.unisonhealthplan.com

20092009

Congratulations to our 2009 Gold Star ProvidersGold Star

ABC Pediatric Care, LLCAGH Pediatric ClinicAll About Childrens Pediatric PartnersAltoona Family PhysiciansAnne C. Martin-Ko, MDBalachandra Chekka, MDBayside Family MedicineBchara F. Janadri, MDBeittel Becker Pediatric AssociatesBellevue Pediatric AssociatesBharati P. Desai, MDBlairsville Family Health CenterCCP Blairsville PediatricsCCP GILCCP JeannetteCCP Mountain View PediatricsCCP Pittsburgh PediatricsCCP Russelton PediatricsCCP South Hills Pediatric AssociatesCherry Tree PediatricsCheryl A. Duffy, MDChildren & Teen CenterChildrens Clinic at LVHChildrens Health Care WestClay Battelle Community Health CenterClementine Abeloff Community Health CenterCornerstone Care Cornerstone Care Community Medical CenterCornerstone Care Pediatric Assoc. of

WashingtonDaniel A. Church, MDDawn McCracken, MDDuy Ba Nguyen, MDEast Suburban Pediatric Associates East York Family MedicineFairview Primary Care PartnersFamily First Health Hannah Penn Center

Family First Health Hanover CenterFamily First Health Lewisberry CenterFrank M. Tursi, DOGettysburg PediatricsGhaffar A. Zafar, MDHamilton Health Center, Inc.Helping Hands PediatricsHilltop Community Healthcare CenterIndiana Pediatric AssociatesJames Street Family MedicineKeystone Rural Health CenterKultar S. Shergill, MDL J Silberman & AssociatesLaurel Pediatric AssociatesLaurel Pediatrics Liberty Family PracticeLittlestown Family Care CenterMatilda R. Sotomayor, MDMcClelland Family PracticeMedical Group of Corry, Inc.Mercy Hospital Ambulatory Pediatric ClinicMetro Family PracticeMilka E. Velazquez, MDMira Slizovsky, MDMountain Area Healthcare, PCMountain Family CareNext Generation PediatricsNorth East Family Practice Northeast Pediatrics, LLCPediatric Adolescent ServicesPediatric Alliance Chartiers /

McMurray DivisionPediatric Alliance Greentree DivisionPediatric Alliance Southwest DivisionPediatric Associates of LatrobePediatric Associates of WestmorelandPediatric Care Center

Pediatric Care SpecialistsPediatric Healthcare AssociatesPhysicianCare, PCPrimary Care Center of Mt. MorrisPrimary Health Network Primary Health Network East Brady & PetroliaRedi Care Physicians, Inc.Rural Health Corp. of Northeastern PASacred Heart Primary CareSaint Vincent Family Medical CenterScranton Primary Health Care CenterSewickley Valley Pediatric & Adolescent

MedicineSomerset Family PracticeSomerset Pediatric & Adolescent Health

CenterSoutheast Lancaster Health ServicesSteel City South PediatricsSto Rox Family Health CenterThe Doctors Office ConnellsvilleTri State Pediatric Associates, Inc.Twin Rose Primary HealthcareUPMC McKeesport LattermanUPP Department of PediatricsWael Yacoub, MDWalter L. Aument Family Health CenterWarren Medical GroupWarren Pediatric AssociatesWaynesburg Family MedicineWelsh Mountain Medical & Dental CenterWhites Crossing Medical CenterWyoming Valley Family PracticeYoung-Kyu Lim, MDYour Pediatric ConnectionZarar M. Bajwa, MD

As a result of their excellence, our 2009 Gold Star providers are re-lieved of all in-network referrals and most prior authorizations.

These benefits will be in effect from April 1, 2009 through March31, 2010.

Gold Star providers will only need approval for:• admission to hospitals, skilled nursing and rehab facilities• services from providers who are not in our network• non-formulary drugs and medications that require prior authoriza-

tion• non-covered benefits

2 P A P R O V I D E R C O N N E C T I O N

UNISONHEALTHPLAN.COM

3

Medicare Reminder: Notice of MedicareNon-Coverage (NOMNC)On behalf of Unison Advantage, CMSrequires Medicare Advantage planproviders to give an advance, completecopy of the Notice of Medicare Non-Coverage (NOMNC) to enrollees re-ceiving Skilled Nursing Facility (SNF),Home Health, or Comprehensive Out-patient Rehabilitation Facility (CORF)services. This notice must be given nolater than two days before the termina-tion of services. The notice outlines themember’s ability to appeal to the Qual-ity Improvement Organization (QIO).

For more information regarding theNOMNC, and how to use it accurately,please refer to the instructions on theCMS website: http://www.cms.hhs.gov/MMCAG/Downloads/NOMNCInstructions.pdf.

The Unison Advantage NOMNC isstate-specific because it includes QIOcontact information. You can find acopy of the CMS-approved NOMNCsfor your state’s Unison Advantage planby going to www.unisonhealthplan.com.From there, select your state from thestate drop-down list, then select UnisonAdvantage from the plan drop-down list.Click on “For Providers,” then click on the“Provider Forms” link to the left. Therewill be a link to the state-specific NOMNC.

Unison is dedicated to assisting you withprecise completion of the Notice ofMedicare Non-Coverage (NOMNC), asrequired by CMS. We hope that youwill also work together with our staff,whose goal is to be compliant with CMSregulations.

Thank you for your cooperation withthis initiative.


UNISON ADVANTAGE PAYMENTS FOR PHYSICIAN ASSISTANTSPhysician assistants have their own ben-efit categories and may provide serviceswithout direct physician supervision andbill directly for these services under theirindividual NPI. Payment for such servicesis approved at the appropriate specialtyallowance according to Medicare regula-tions. When the services of non-physicianpractitioners are provided as auxiliarypersonnel under direct physician supervi-sion, they may be covered as incidental toservices, in which case the incidental re-quirements as specified above apply. Inthis situation, the services are reportedunder the supervising physician’s NPIand payment is approved at the appropri-ate physician fee schedule allowance.

Pending Change to UM GuidelinesUnison Health Plan is now part ofAmeriChoice. In an effort to create aunified medical management approachfor all of AmeriChoice business units,the decision has been made to adoptthe Milliman Care Guidelines for allplans as the primary written utilizationdecision criteria used to determine med-ical necessity. The Milliman CareGuidelines include the following criteria:Ambulatory Care, Inpatient & SurgicalCare; General RecoveryGuidelines; RecoveryFacility Care; andHome Care.

Milliman CareGuidelines areupdated annu-ally and spanthe continuumof care prod-ucts. The

Care Guidelines provide healthcare pro-fessionals with evidence-based clinicalprinciples, which address medical condi-tions at the point of care. The guide-lines also support prospective,concurrent, and retrospective reviews;

proactive care management; dischargeplanning; patient education, and qualityinitiatives. These Care Guidelines incor-porate the quality measures used in na-tionally known accreditationorganizations such as the Hospital Qual-

ity Alliance (HQA), NCQA and theJoint Commission.

Unison has written the Pennsylva-nia Department of Public Wel-

fare and the PennsylvaniaDepartment of Insurance

and requested approvalof this change. It isanticipated thechange will takeplace in September2009. We will pro-vide detailed infor-mation whenregulatory approvalis received.

S P R I N G 2 0 0 9


Allergic Rhinitis (AR) is a highly prevalent disease, affecting 20-40 million Americansannually, including 10-30 % of adults and up to 40 % of children. It is the sixth mostcommon chronic illness in the US, and is one of the most common reasons patientsseek medical care. Common nasal symptoms include sneezing, rhinorrhea, itching,post-nasal drainage, and congestion. AR significantly impacts quality of life and cre-ates a substantial economic impact, with estimates as high as $5.3 billion-$7.7 billion.

Currently, numerous pharmacologic options are available for the treatment of AR,including oral decongestants, first and second-generation antihistamines, mast cellstabilizers, inhaled nasal steroids (INS), leukotriene receptor antagonists (LTRAs),and nasal anticholinergics. Antihistamines and INSs are the most frequently usedmedications to treat the symptoms of allergic rhinitis. Established guidelines by theWHO have deemed INSs as the most effective treatment of AR, although antihista-mines are first line treatment for mild intermittent symptoms of AR. The most re-cent class of medications to be approved for the treatment of AR is the LTRAs;however current literature revealed they were no more effective than second gener-ation antihistamines and were less effective than INSs for treatment of AR.

Unison is committed to providing pharmacotherapeutic options for AR which areboth clinically and cost effective. Current Unison formularies provide:


WE’RE ONLINEAt www.unisonhealthplan.com, you haveready access to information on our Med-PLUS, Kids, aB, and Unison Advantagehealth plans.�claims status�eligibility status�reference (authorization) status�appeal status�billing alerts�our latest clinical and preventive

health guidelines�new technology evaluation policy�health management programs �medical record requirements�UM (utilization management) proce-

dure and availability of UM reviewer �availability and how to contact the

medical director�availability of QI programs�pharmacy program, formulary and ex-

ception process�provider manual�member rights & responsibilities�member complaint procedure

Go to www.unisonhealthplan.com: selectPennsylvania from the pull down bar, se-lect a plan. Click on “For Providers.” Ifyou do not have a web account, click“Account Information.” Click “create anaccount” and follow directions. You canalso call Web Outreach for assistance1.866.414.6566.

Printed copies of the information on ourwebsite are available by calling ProviderServices at 1.800.600.9007.

Taking Control of Allergic Rhinitis

INHALED NASAL STEROIDS UNISON PREFERRED AVG. COST/MONTH

Fluticasone propionate (Flonase) Yes $15.00Flunisolide, Rhinocort AQ, No $55.00-$100.00Omnaris, Nasonex, Nasacort AQ,Beconase AQ, Veramyst

SECOND GENERATION UNISON PREFERRED AVG.COST/MONTHANTIHISTAMINES

Loratadine (Claritin), Yes $6.00Cetirizine (Zyrtec) Yes $6.00Fexofenadine (Allegra) Yes (after step therapy) $30.00Clarinex, Xyzal No $42.00-$122.00

LEUKOTRIENE RECEPTOR UNISON PREFERRED AVG.COST/MONTHANTAGONISTS

Singulair Yes (after step therapy) $130.00

The National Committee for QualityAssurance (NCQA), our accrediting or-ganization, uses the Healthcare Effec-tiveness Data and Information Set(HEDIS®) to measure the performanceof health plans. More than 90 percentof America’s health plans use this tool toevaluate care and service. In establishingwhat to evaluate, HEDIS® looks at thescientific soundness, relevance and fea-sibility of clinical areas. For example,HEDIS® weighs the health importance,clinical support and impact to the popu-lation. In addition, cost effectivenessand potential for improvement are alsoconsidered.

For 2009 HEDIS®, two new measureswere introduced for look back. The newmeasures are Adult BMI Assessment andWeight Assessment and Counseling forNutrition and Physical Activity forChildren and Adolescents. According tothe CDC, obesity continues to be ahealth concern for adults, children andadolescents in the United States. Resultsfrom the most recent National Healthand Nutrition Examination Survey(NHANES) show that among adult menand women the prevalence of obesitywas 33.3% and 35.3% respectively in2005-6. A NHANES survey also foundthat 16.3% of children and adolescentsaged 2–19 years were obese, at or abovethe 95th percentile of the BMI-for-agegrowth charts.

This rate of obesity raises concern as itincreases the risk of many diseases and

health conditions including: coronaryheart disease; type 2 diabetes; cancers(endometrial, breast, and colon); hyper-tension; dyslipidemia; stroke; liver andgallbladder disease; sleep apnea and res-piratory problems; osteoarthritis; andgynecological problems (abnormalmenses, infertility).

BMI provides a reliable indicator ofbody fat for most people and is effectivein screening for weight categories thatmay lead to these health problems. TheAdult BMI Assessment measure includesthe percentage of members 18-74 yearsof age who had an outpatient visit andhad their body mass index (BMI) docu-mented during the measurement year orthe prior year.

The Weight Assessment and Counsel-ing for Nutrition and Physical Activityfor Children and Adolescents measureincludes the percentage of members 2-17 years of age who had an outpatientvisit with a PCP or OB/GYN and whohad evidence of BMI percentile docu-mentation, counseling for nutrition andphysical activity during the measure-ment year. Because BMI norms foryouth vary with age and gender, thismeasure evaluates whether BMIpercentile is assessed ratherthan an absolute BMI value.

Your efforts to provide ourmembers with the best pos-sible care is valued andappreciated. Please seek

every opportunity to provide these valu-able screenings to our members. We areproud of the performance our providersand programs have delivered to ourmembers. Continuous improvement isour goal, and we look to even betterperformance in the future.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

HEDIS® Measures


UNISON PRACTICE GUIDELINESUnison Health Plan’s practice guidelinescan be found on our website or printedcopies can be requested from ProviderServices. Current guidelines cover Pre-ventive Health Maintenance for children(including the EPSDT periodicity table),adults and pregnancy. The followingclinical practice guidelines are also pro-vided: asthma; ADHD; major depression;diabetes; cholesterol care; chronic kid-ney disease; treatment of COPD; con-gestive heart failure; care of HIVpatients: hypertension care; pediatricobesity; respiratory illness, schizophre-nia; sickle cell disease. The guidelinesare reviewed and updated annually.Each guideline reflects the guidelinesrecommended by a recognized nationalor international medical group. A link tothe full text of each guideline is providedfrom our website.

Unison Formulary UpdateThe Unison Formulary is available on the internet at www.unisonhealthplan.com. For the most up-to-date information pleasevisit our site, which includes recent P&T decisions for Unison MedPLUS and Kids regarding second generation antipsy-chotics, Prezista, Ortho Tri Cyclen Lo, Insulin, Inflamase Mild, hydrocortisone lotion, HMS Liquifilm, fluocinolone cream,Finacea gel, and desonide cream, ointment and lotion.

Complete formulary information is also accessible through the Epocrates Formulary tool at www.epocrates.com.



One of Unison’s primary goals of theGold Star Pay-for-Performance Programis to partner with our Primary CarePractices to deliver quality, cost effec-tive care to our membership. We takegreat pleasure in recognizing these spe-cial partnerships by sharing a shiningexample with you.

Blairsville Family Practice in IndianaCounty is now a three time Gold Stardesignee. Nancy Gould, RN states,“Unison’s Gold Star Program is by farthe most obtainable pay-for-perfor-mance program out there!” The staff andphysicians at this practice have goneabove and beyond to provide excellentservices to our members while exceed-ing our expectations of quality.

In an effort to continually improve theirquality scores for Gold Star, two office

staff members are specificallydedicated to review Unison re-ports. These dedicated individu-als use these reports to callUnison patients and remindthem to come in for neededservices such as cholesterolscreenings or EPSDT examsas soon as possible.These staffmembers acknowledge that it takes a lotof work to be successful, but state the“Gold Star designation is well worth it!”

In addition to their outreach campaigns,this practice has gone further by con-ducting a “Unison Day” for their pa-tients in order to increase cervicalcancer screening and mammographyservices for their patients using a mobilemammography unit at their office.

Unison is proud of themilestones like these that have been metby our providers to improve the GoldStar Program and could not be morepleased to congratulate not onlyBlairsville Family Practice, but all of our2009 Gold Star designees.

Photo (Above): Blairsville Family Practice Staff memberswearing shirts that were purchased with a portion of their2008 Gold Star award

Provider Spotlight

The Unison Quality Improvement Pro-gram is designed to continually evalu-ate, monitor, and improve the quality ofcare and services Unison provides. Theprogram identifies and recommendsways to improve health care and relatedservices delivered to Unison membersthrough the use of continuous QualityImprovement (QI) concepts and meth-ods, including:� Evaluating clinical and administrative

aspects of care and services providedto members to determine areas for im-provement

� Recommending corrective plans ofaction to improve the quality of careand service

� Implementing the plans of action

� Measuring the effectiveness of inter-ventions to improve the quality ofcare, customer service and the healthstatus for the members it serves.

Unison has a Quality Improvement/Uti-lization Management (QI/UM) Com-mittee composed of physicians andUnison management staff. Participatingphysicians give Unison advice and ex-pert counsel in medical policy, qualitymanagement, and QI. The QI/UMCommittee reports its recommendationsand actions to the Unison ExecutiveQuality Improvement Committee.Joseph Sheridan, D.O., UHPPA Med-ical Director, chairs the QI/UM Com-mittee.

QI program activities are coordinatedon a calendar year basis. The QI/UMProgram Description and Work Planidentify the yearly activities that sup-port the QI program.

For more information on Unison’s QIProgram, contact Marie Hawranko,UHPPA Vice President of QI(1.412.457.1810).

Improving Quality is KeyNEW TECHNOLOGY AND TREATMENTSUnison routinely reviews new medicaland behavioral health procedures andservices to improve the health and wellbeing of our members. As new, evidence-based, and clinically important knowl-edge becomes available, we seekopportunities to support you in incorpo-rating that knowledge into your medicalpractice. If a physician or equivalently li-censed professional requests somethingnew to treat a Unison member, we inves-tigate it and make a coverage decision.Any treatment, drug, or device that is notexperimental is reviewed. We advise boththe member and provider what the deci-sion is.

When new services and treatments be-come covered benefits providers andmembers will receive communication.

S P R I N G 2 0 0 9


Childhood exposure to lead continuesto be a major health problem in thiscountry, particularly among Medicaideligible children. Eliminating blood leadlevels >10 µg/dL in children is one ofthe national objectives for Healthy Peo-ple 2010. According to the NationalHealth and Nutrition Examination Sur-veys (NHANES) from the period1976—1980 to 1991—1994, the per-centage of children aged 1—5 yearswith elevated blood lead levels has de-clined steeply. However, blood lead lev-els remain higher for certain

populations, especially children in mi-nority populations, children from low-income families, and children who livein older homes.

It is a requirement of CMS that a bloodlead test be used when screening Medi-caid-eligible children. Federal policy re-quires that all children enrolled inMedicaid receive screening blood leadtests at ages 12 and 24 months and thatblood lead screening be performed forchildren aged 36—72 months who havenot been screened previously. A blood

lead test result > 10 ug/dl obtained bycapillary specimen (fingerstick) must beconfirmed using a venous blood sample.Please help us help our members. Makeblood lead screening part of your rou-tine well-childexams foryoung Unisonmembers.

Blood Lead Screening & Young Children on Medicaid

Health insurance fraud, waste and abuseaffect everyone. It adds up to billions ofdollars misspent healthcare dollars. Youcan assist Unison with identifying mem-ber fraud by notifying us if you suspecta Unison member of being involved in afraudulent activity.

EXAMPLES OF RECIPIENT FRAUD� Loaning his/her insurance card to an-

other individual

� Forging or altering a prescription

� Using multiple identification cards

� Intentionally receiving duplicate, ex-cessive or conflicting health care serv-ices or supplies

� Re-selling items provided by the in-surance program

HOW CAN PROVIDERS ASSIST UNISON WITHIDENTIFYING MEMBER FRAUD? � Ask the member for identification if

you are unsure if the individual pre-senting a Unison identification card isthe individual named on the card

� Notify Unison if you suspect an indi-vidual has tried to use more than oneidentification card or a card belongingto another individual

� Notify Unison if you are concernedbecause the individual appears to betrying to obtain unnecessary servicesor supplies

If you suspect fraud, waste and abuse,please contact our toll free hotline at 1-877-766-3844 or fill out a referral format www.unisonhealthplan.com/_lay-outs/unison/fraudabusesubmit.aspx.

Medical Assistance - The PennsylvaniaDepartment of Public Welfare has a MAProvider Compliance Hotline to reportsuspected fraud and abuse committedby any entity providing services toMedical Assistance recipients. The hot-line number is 1.866.DPW.TIPS(1.866.379.8477) and operates betweenthe hours of 8:30 AM and 3:30 PM,Monday through Friday. Voice mail isavailable at all other times. Callers may

remain anonymous and may call afterhours and leave a voice mail if they pre-fer. Suspected fraud and abuse may alsobe reported via the website at:www.dpw.state.pa.us/omap or email [email protected]. Information re-ported via the website or email can alsobe done anonymously.

Medicare - The US Office of InspectorGeneral has several confidential ways toreport fraud and abuse committed byany entity providing services toMedicare recipients. By Phone: 1.800.HHS.TIPS(1.800.447.8477)By Fax: 1.800.223.2164 (no more than10 pages please)By E-Mail: [email protected] Mail: Office of the Inspector GeneralHHS TIPS HotlineP.O. Box 23489Washington, DC 20026

Help Stop Insurance Fraud

To encourage our members to seek this screening, we offer a gift card reward to members for children screened at 12 months. We issue the gift card when we have claims data supporting the blood lead test.


Presorted StandardU.S. Postage

PAIDPittsburgh, PA

Permit No. 4503

Unison Administrative ServicesUnison Plaza

1001 Brinton RoadPittsburgh, PA 15221

www.unisonhealthplan.com


PROVIDER RELATIONS TEAM

Executive Director - PennsylvaniaMichael J. Fantoni Phone: 412.858.4362E-mail: [email protected]

HOSPITAL RELATIONSSupervisor, Hospital RelationsDarlene Ferguson Phone:412.418.6485E-mail: [email protected]

ANCILLARY PROVIDERSManager of Ancillary Provider RelationsDenise Romeo Phone: 412.858.4038E-mail: [email protected]

EASTERN PENNSYLVANIADirector of Provider Relations Jason Dadey Phone: 412.457.1805 E-mail: [email protected]

Manager of Provider Relations, Donna Lambert Phone: 412.349.6244E-mail: [email protected]

Supervisor of Provider Relations Brenda Welch Phone: 412.349.6111E-mail: [email protected]

WESTERN PENNSYLVANIAManager of Provider RelationsLaura MoughPhone: 412.380.8017E-mail: [email protected]

Supervisor of Provider RelationsRochelle PuskarPhone: 412.856.5041E-mail: [email protected]

A complete listing of Provider Relations representatives by county is available on our website.

REPORTABLE DISEASES REMINDER Physicians, hospitals, and clinical laboratories are legally required to report certain diseases and conditions to public health agencies. For ex-ample, a child with lead toxicity needs medical treatment, but the case also requires public health intervention to remove lead hazards from thechild’s environment.

Providers diagnosing a reportable condition must report the case to the county or municipal health department, if present in the provider’s prac-tice area. Otherwise, the report should be sent to the Pennsylvania Department of Health. Some of the conditions require immediate reporting bytelephone. The current list of reportable diseases and conditions are available on the PA Department of Health website at http://www.pabul-letin.com/secure/data/vol32/32-4/161d.html.

P R O V I D E R A N N O U N C E M E N T


CMS Requirements Related to Medicare Special Needs PlansThe Medicare Improvements for Patients and Providers Act (MIPPA) andCMS regulations 42 CFR§422.152(a)(1), (2) and (3) require implementation of quality improvementprojects on an annual basis, implemen-tation of chronic care improvement pro-grams, and the encouragement of planproviders to participate in CMS andHHS quality improvement initiatives.

The Special Needs Plan (SNP) qualityimprovement program is three tiered in-cluding (1) HEDIS® measures, andstructure and processmeasures; (2) establishmentof a chroniccare improvementprogram andquality improvementprojects to favorably impact healthoutcomes

and beneficiary satisfaction; and3) CMS monitoring of care manage-ment implementation through the collection, analysis and reporting toCMS of selected data that measure theeffectiveness of SNP models of care.

Tier three includes the structure andprocess measures that require ManagedCare Organizations to manage theprocess of care transitions of SNP mem-bers, identify problems that could causetransitions and when possible preventtransitions. A transition is defined byCMS as the movement of a memberfrom one care setting to another as themember’s health status changes. For example, moving from the hospital to arehabilitation facility after surgery.

Management of a safe care transitionprocess will require collaboration be-

tween Medicare Managed Care Organ-izations and contracted providers toensure the following elements are com-pleted:

�Identification of an impendingcare transition

� Sharing the mem-ber’s care plan withthe care setting re-ceiving the memberwithin one businessday of notificationof the transfer

� Communicat-ing the caretransitionprocess to themember or responsibleparty

� Communicating changes to the mem-ber’s health status and plan of care tothe member orresponsible party

� Ensuring the member’s usual practitioner is notified of a care transi-tion

In addition, Unison wants its dual-eligible Medicare Special Needspopulation with multiple or complexconditions to obtain services seamlessly,whether they are reimbursed byMedicare or Medicaid. Your role as aSNP provider is to coordinate the services provided. For physician servicesfor which Medicaid pays the Medicarecopayment, physicians are expected todo one of the following:1)Accept both Medicare and Medicaidpayment and do not bill patients morethan any co-payment required by thestate, or 2) If only accepting Medicare, do notbalance-bill dual-eligible members forco-payments paid by Medicaid.

We can help you with member ques-tions about their Medicare and Medicaid benefits. You can contact ourProvider Services line at 1.800.600.9007for assistance. Dual-eligible membersmay call Member Services at1.800.290.4009. TTY users should call711 or 1.888.616.0021. In addition,benefit information is available atwww.unisonhealthplan.com.

The AmeriChoice Medicare ManagedCare Organizations, including Unison,are developing additional processes tosupport dual-eligible coordination thatare scheduled to be in place by 2010.The Unison Provider Relations teamwill be providing education and supportas we work toward meeting the uniqueneeds of the SNP Medicare membership.

UNISON PROVIDER ANNOUNCEMENT

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

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