Subcontracting Reminder Convenience Care … Community Plan partnered with Tennessee Health Care...

For more information

Call our Provider Service Centerat 800-557-9933

Visit UHCCommunityPlan.com

In This Issue:

• Convenience Care Clinics ExpandsMember Services . . . . . . . . . . . . . . . . . 1

• Physician Satisfaction SurveyUnderway . . . . . . . . . . . . . . . . . . . . . . . 2

• Prompt Responses to MedicarePart D Prescription Appeals InquiriesEnsure Continuity of Care . . . . . . . . . 2

• New Clinical Guidelinesfor UnitedHealthcare CommunityPlan . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

• National Institute for MentalHealth Resources: Focus onMedications . . . . . . . . . . . . . . . . . . . . . 3

• When Forces Collide: TraumaticBrain Injury Masquerading asADHD in Adolescents . . . . . . . . . . . . 3

• UnitedHealthcare CommunityPlan Provider Portal Online-Authorizations and NotificationProcess . . . . . . . . . . . . . . . . . . . . . . . . . 6

• Getting Started with EDI is simple . . 7

Important information from UnitedHealthcare for physicians and other health careprofessionals and facilities serving UnitedHealthcare Medicaid members

Convenience Care Clinics Expands MemberServicesUnitedHealthcare Community Plan has recently expanded ourprovider network to include walk-in clinics at various TakeCareHealth Clinics (Walgreens) and Minute Clinics (CVS) stores inOhio, Texas, New York,Wisconsin, Mississippi and Delaware.When provided with primary care physician information, theconvenience care clinic will make every attempt to submitnotification to that primary care physician to ensure continuityand quality of care. Convenience care clinic staff do not assistpatients with referrals for specialty care services. Convenience careclinics treat patients over the age of 19 months and will not beoffering immunizations for the vaccine for children (VFC)program in this setting. Convenience Care Clinics offer extendedhours, and in most cases are open until 8:00 pm.

Some common conditions that can be treated in the conveniencecare clinics:

Vaccines• Flu (seasonal)• Hepatitis A (adult)• Hepatitis (adult)• Meningitis• Pneumonia• Td (Tetanus, Diphtheria)

Fall 2012

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Tennessee | Winter 2012


Subcontracting ReminderUnitedHealthcare Community Plan would like to remind physicians and other health care professionals that they may not enter into subsequent agreements or subcontracts for any of the work contemplated under their agreement without the prior written approval of UnitedHealthcare. If a physicians and other health care professional subcontracts or delegates any functions of the agreement, in accordance with the terms of the agreement, the subcontract or delegation must include all of the requirements stated in the UnitedHealthcare Community Plan Provider Manual, and applicable requirements of the Contractor Risk Agreement (CRA). Providers must also agree to promptly amend agreements with subcontractors, in the manner requested by UnitedHealthcare Community Plan, to meet any additional TennCare requirements that may apply to the services. In addition, physicians and other health care professionals must agree and acknowledge that subcontracts require prior approval by the Bureau of TennCare and Tennessee Department of Commerce and Insurance. For further information regarding subcontracts please consult the UnitedHealthcare Community Plan Provider Manual, the CRA or contact your Provider Relations Advocate via customer service 800-690-1606.

ICD-10 Reminder UnitedHealthcare Community Plan would like to remind physicians and other health care professionals that on Aug. 24, 2012 the United States Department of Health and Human Services announced a change in the compliance date for the International Classification of Diseases (ICD), 10th Edition (ICD-10-CM and ICD-10-PCS) Medical Data Code Sets.

In This Issue:• Subcontracting Reminder ..................... 1

• ICD-10 Reminder ................................ 1

• Checkups for Children ......................... 2

• Preventive Health Care Screenings for Adults ............................ 2

• CHOICES Nursing Facility Providers................................... 3

• Cultural Needs ...................................... 4

• Documentation of Recommended Assessments ................. 4

• TennCare Disclosure Forms ................. 5

• Anti-Depressant Medication Management and Prescriber Attestation Process ................................ 6

• How Does the Prescriber Attestation Process Work? .................... 6

• Inside the Star Rating Initiative With James Carney, MD, MBA ........... 8

• Getting Started With EDI is Simple ............................................... 9

• Quality Improvement Program ........... 10

• Pharmacy Updates .............................. 11

• Global Days Policy Reminder ............. 11

• Updated Information About 17 Alpha-Hydroxyprogesterone Caproate (17P) Injection .................... 12

• Recovery and Adherence .................... 14

For more information

Call our Provider Service Center at 800-690-1606

Visit UHCCommunityPlan.com

http://UHCCommunityPlan.com

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A one year implementation delay was approved, moving the compliance date for use of the ICD-10 diagnosis and procedure codes from Oct. 1, 2013 to October 1, 2014. This final rule was published in the Federal Register on Sept. 5, 2012 and becomes effective, Nov. 5, 2012.

UnitedHealthcare Community Plan remains committed to timely ICD-10 compliance and continues to actively prepare for the October 2014 implementation date. For additional information regarding ICD-10, please contact your UnitedHealthcare Community Plan Network Provider Advocate via our customer service line 800-690-1606.

Checkups for ChildrenTENNderCare is a component of the federal Medicaid program which provides full service healthcare for children from birth to age 21 who receive TennCare. TENNderCare services also include follow-up recommendations for medically necessary care and/or treatment.

Each of the following should be performed at every EPSDT checkup:

• Comprehensive Health (physical & behavioral) and Developmental History

• Complete Physical Exam (unclothed or appropriately draped)

• Immunizations• Lab tests• Vision Screening• Hearing Screening• Anticipatory Guidance

Please help keep our members healthy and remind them to get regularly scheduled EPSDT checkups!

Preventive Health Care Screenings for AdultsRecommended preventive health care service for TENNderCare members is covered by United Healthcare Community Plan. Adult screenings are equally as important as TENNderCare exams. The preventive benefits help both children and adults detect problems early and take an active role in maintaining good health.

These general guidelines list the types of care screenings and exams needed at particular ages.

• For infants and young children, the guidelines typically focus on physical and mental development, immunizations, nutrition, and safety.

• For children and young adults, the focus is usually on maintaining or developing healthy lifestyle habits and eliminating high-risk behaviors.

• For adults, the focus continues to be on eliminating high-risk behaviors; however, screening for chronic and/or life-threatening disease becomes more important.

The choices members make about the way they live are important to their health. As their physician, please talk to them about the importance of preventive services and what services they might need. Remind them that it is important to follow your advice about checkups, healthy lifestyle choices and medications that prevent health problems. Always encourage regular screenings that assist in keeping patients healthy.

UnitedHealthcare Community Plan partnered with Tennessee Health Care Association (THCA) and Tennessee Health Care Education Foundation (THCEF) to provide grant opportunities to individuals to pursue careers in the long term care industry.

TN - Winter 2012 Provider Service Center: 800-690-1606

Important information for health care professionals and facilities

I Fall 2012 2 Provider Service Center: 800-557-9933

Illnesses• Bladder infection treatment (females 12-65)• Bronchitis (ages 10-65)• Laryngitis• Ear infections• Pinkeye and styes• Sinus infections (ages five and up)• Strep throat• Swimmer’s ear

Skin Conditions• Athlete’s foot• Acne• Cold sores (ages 12 and up)• Deer tick bites (ages 12 and up)• Impetigo• Minor burns and rashes• Minor sunburn• Poison ivy (ages three and up)• Scabies• Shingles• Ringworm• Swimmer’s itch (ages three and up)

Other servicesFlu diagnosis (ages 10-64)• Mononucleosis• Pregnancy testing

Physician Satisfaction SurveyUnderway

The annual PhysicianSatisfaction Survey processhas begun, and you shouldhave received your first faxnotification. There willbe two more invitations toparticipate before thesurvey closes in October.

Your response letsUnitedHealthcareCommunity Plan know

how we can improve our working relationshipand better meet the needs of your practice. Welook forward to your participation in the surveyprocess.

Prompt Responses to Medicare Part DPrescription Appeals Inquiries EnsureContinuity of Care

When you or your patient, files an appeal withUnitedHealthcare, we will contact your office viafax or phone to request certain key informationneeded as part of the appeal process.

By federal law, UnitedHealthcare must render anappeal decision within 72 hours for an expeditedrequest and seven calendar days for a standardrequest.

Your assistance in responding to these requestspromptly helps ensure continuity of themember’s treatment plan.

New Clinical GuidelinesUnitedHealthcare Community Plan

UnitedHealthcare Community Plan Pharmacyand Therapeutic Committee has approved a newclinical guideline for Antiemetic ContinuousPump Therapy for the Treatment of Nausea andVomiting in Pregnancy.

Notification - Effective Oct. 1, 2012, the use ofAntiemetic Medication through a continuoussubcutaneous pump in the treatment of nauseaand vomiting in pregnancy will no longer becovered under UnitedHealthcare CommunityPlan.

Providers may request clinical review criteria bycontacting the Pharmacy Prior Notificationdepartment at 800-310-6826.



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UnitedHealthcare Community Plan developed the CARE grant C, Creating Advancement Recognizing Education, to support direct staff working in long term care to further their education. The grants were developed through Member Advocacy workforce development initiatives and led by CHOICES Member Advocate, Beth Zanolini.

To qualify for the grant individual must work for a long term care facility that is contracted with UnitedHealthcare, be in good standing with the facility, and must work for a facility that has expanded to provide home and community based services. Additional individual qualifications and background information are assessed per candidate. Grant opportunities include: certification, associate, and bachelor level degrees.

Applications for the grant were received, reviewed and nominated by a THCEF committee. Fay Cox, Patient Care Technician with Trousdale Senior Living Center, was the first UnitedHealthcare CARE grant recipient.

Faye received a $2,500 CARE grant scholarship to pursue her LPN degree at Volunteer State Community College. Fay has been a Patient Care Technician at Trousdale Senior Living Center for fourteen months. She is also a caregiver to her husband. Prior to working with Trousdale Senior Living Center, she worked in a factory for 30 years. When the factory closed and moved Faye was unemployed.

Faye wrote, “I have come to know and love each and every one of them [patients].Working there [Trousdale Senior Living] has made me realize how much I want to become a nurse. My inner ambition is to help others to the best of my ability while continually learning from each situation. Becoming a LPN is a job I can do for many years to come and is a career path that I am proud to pursue. I love helping people and with the Lord’s help, I can do a lot of good and help a lot of people.”

Fay also wanted to extend a huge thank you to UnitedHealthcare for helping make her dream come true.

UnitedHealthcare congratulates Fay Cox and wishes her the best in her new career path.

CHOICES Nursing Facility ProvidersTo work to reduce Fraud, Waste and Abuse, on Sept. 1, 2012, UnitedHealthcare upgraded systems to improve our ability to audit for submission of clean inpatient claims. These edits are based on the CMS Medicare Code Edits (MCE) criteria. For a full listing of the edits please reference the CMS website at cms.gov.

Here is a sample of the audit types included in the enhancement:

• All diagnoses submitted must have the appropriate number of digits

• Admission and discharge dates must be chronological

• Diagnoses and procedures must be appropriate for the gender of the patient

• An “E” code cannot be billed as a principal diagnosis

• Diagnosis or procedure code is invalid for date of admission or discharge

• Manifestation code cannot be used as principal diagnosis (the principal diagnosis must be coded first, then the manifestation of the disease would be a secondary diagnosis)

If a claim is denied for one or more of these reasons, the facility can submit a Corrected Claim through the process outlined in the UnitedHealthcare Community Plan Provider





















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Administration Manual (pages VI-6 and VI-7). The UnitedHealthcare Community Plan Provider Administration Manual is located at UHCCommunityPlan.com.

Cultural NeedsUnitedHealthcare Community Plan participates in the state’s efforts to promote the delivery of health care services in a culturally competent manner to all enrollees, including those with limited English proficiency and diverse cultural and ethnic backgrounds. Information regarding primary language is obtained upon enrollment. We then assess our practitioner availability to insure that the cultural, ethnic, racial, and linguistic needs of our members are being met. The Provider Directory is available on the web at UHCCommunityPlan.com, and lists the languages spoken in the provider’s office.

We offer our member newsletters and other publications in alternative formats (Braille, large print) and other languages. Members can call 800-690-1606 to request these materials. Additionally, UnitedHealthcare

Community Plan provides access to a language line for translation of communication between UnitedHealthcare Community Plan staff and non-English speaking members. Language line use is free to TennCare enrollees and its use is tracked by the Customer Service Center and reported regularly to the Health Plan.

Documentation of Recommended AssessmentsCollecting a thorough history is an important part of any EPSDT exam. Detailed documentation in the medical record should include ALL required parts of a history. It is highly encouraged that recommended assessments be addressed including a Nutritional Assessment, Cholesterol Assessment, and a Lead Risk Assessment. The following are the areas of focus for recommended assessments. Addressing all parts of the history during the EPSDT exam is important for good quality of care for each child.

Recommended Assessments Areas of Focus for Documentation

Nutritional Assessment Dietary practices, unusual eating habits, quality and quantity of the individual’s diet and diets which are deficient or excessive in one or more areas should be addressed.

Cholesterol Risk Assessment Cholesterol Risk Assessment (beginning at age two) should include: • Parent or grandparent with coronary or peripheral vascular disease before age 55 • Parent with elevated blood cholesterol • Child with risk factors for future coronary disease (physical inactivity, obesity, diabetes mellitus)

Lead Risk Assessment Lead risk assessment begins at six months and then occurs at every encounter through 72 months.



TennCare Disclosure FormsTennCare Website for the forms: http://www.tn.gov/tenncare/ disclosure.shtml

Federal Regulations in 42 USCA 1396a(p) and 42 C.F.R. §438 require that the State plan monitor the payments of Medicaid funds to providers. The Disclosure of Ownership form must be submitted at the time a provider is validated (re-accredited/re-credentialed) by the Managed Care Organization (MCO), or whenever there is a material change in the information required by this form.

Disclosure of Ownership and Control forms are obtained on all providers as a requirement for participation in the UnitedHealthcare Community Plan network. Non-plan, non-network providers will also be required to furnish UnitedHealthcare Community Plan with a completed disclosure. New Disclosures are obtained at initiation of new provider contract, contract renewal, change of provider information, and re-validated every 36 months to include non-credentialed (i.e. hospital based, facility or ancillary) or non-participating, non-network providers or upon request by TennCare or State agencies.

UnitedHealthcare Community Plan may refuse to enter into a new provider agreement or renew a provider agreement if any person who has an ownership or control interest in the provider, or who is an agent or managing employee of the provider, has been convicted of a criminal offense in any program established under Medicare, Medicaid, or the Title XX Services program.

Payments will not be made to providers for services provided to TennCare Members without a completed disclosure form on file.

Providers must submit the applicable form. All Disclosure of Ownership and Control Interest Statements will be verified by ensuring that all applicable questions have been answered completely. All fields must be completed; if a field is not applicable N/A can be used to populate the field by the person completing the form.

Expiration of Disclosures occurs at 36 months from the signature date of the provider or provider’s authorized representative. Providers will be contacted by UHCCP for replacement Disclosures as needed.

• Disclosure Form for Provider Person A sole Provider Person will use the Provider Person form, filling out info for both themselves and their Provider Entity. All other Provider Entities will fill out the Provider Entity form for the Provider Entity and one Provider Person form for each Provider Person, if the Provider Person does not have a current form on file.

• Disclosure Form For Provider Entities A Provider Entity is a business entity. i.e. a partnership or corporation, that provides TennCare covered services to TennCare enrollees.

FAQs:1. If a Provider Entity is adding a Provider

Person, and the addition doesn’t change the ownership or control of the Entity, no new form for the Entity needs to be filled out.

2. Signature must be written signature of either the Provider Person for that form, or of an individual with the power to legally bind the entity for the Provider Entity form. Signatures of office managers or administrative assistants are not acceptable.

3. Make sure sections that do not require an answer have an n/a on the form.





















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http://www.tn.gov/tenncare/disclosure.shtml

http://www.tn.gov/tenncare/disclosure.shtml



4. A sole Provider Person will use the Provider Person form, filling out info for both themselves and their Provider Entity. All other Provider Entities will fill out The Provider Entity form for the Provider Entity and one Provider Person form for each Provider Person, if the Provider Person does not have a current form on file.

5. Managing employee information is a new requirement under the health care laws. We are defining this term as people who head up the various business functions of the Provider Entity. Therefore they will include such individuals as the heads of accounting/billing, personnel, nursing departments, outpatient services, emergency rooms, managing partners, etc.

6. SSN’s need only be provided for Individuals with an Ownership or Control Interest &/or Managing employees if the entity is incorporated. SSN’s must be provided whether or not the corporation is a for profit or not for profit entity.

7. On the Provider Person form, in the section I Provider address please list the address(s) at which the Provider Person practices. If the Provider Person does not have 1 or 2 address(s) where they primarily practice, list the main address of the Provider Entity.

8. Civil Monetary Penalties need only be reported if they have been imposed by a court order or specifically mentioned in a settlement agreement.

Anti-Depressant Medication Management and Prescriber Attestation ProcessTo support increased patient adherence to anti-depressant medications, UnitedHealthcare Community Plan’s Clinical Quality Management Program monitors pharmacy data related to anti-depressant medications prescribed to patients.

In your practice you may encounter patients who have met their TennCare pharmacy prescription limit. Through the Prescriber Attestation Process, additional medications can be approved for patients currently at their monthly prescription limit (>5 prescriptions or >2 brand medications) who are at a high risk for adverse health consequences and could be hospitalized, institutionalized, or die, within the next ninety (90) days without the requested drug(s).

How Does the Prescriber Attestation Process Work? The prescriber determines that an additional prescription is needed to prevent serious health consequences, and the drug in question is not on the Auto-Exemption List (formerly known as the “Short List”).

The drug the prescriber wants TennCare to cover is on the Prescriber Attestation List.

The prescriber or prescriber’s agent must initiate a telephone call to TennCare’s pharmacy benefit manager, SXC Health Solutions 866-434-5524.

For acute medications, in which no greater than a one-month supply is requested, the prescriber must attest that without access to the requested drug, the patient is at high risk for health consequences that are serious enough to result in hospitalization, institutionalization or death within the next 90 days.





















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For a drug that may be needed for longer than a one-month period (chronic medications), the prescriber must review the patient’s full medication profile with a clinical pharmacist at SXC and subsequently attest that no viable option exists to substitute one of the drugs the patient receives under the prescription limit for the drug for which the special exemption is sought.

An individualized attestation form is faxed to the prescriber immediately following the telephone call for signature. The form must then be signed by the prescriber and FAXED back to SXC as soon as possible.

Requests for which a signed attestation form is not received within three days are closed, and a new request must then be called in.

The patient receives the prescription that helps avert an immediate threat of severe consequences.

Key PointsRecipients should not exhaust their prescription limits on discretionary drugs and then seek attestation for essential drugs.

Prescribers should substitute from the Auto-Exemption List whenever possible.

Prescribers should prescribe combination products and 31 day supplies when appropriate.

Prescription limit override requests are not considered for medications outside of the classes on the Prescriber Attestation Drug List.

All Preferred Drug List, step therapy, clinical criteria, and utilization edits/criteria apply.

Antibiotics Antipsychotics Nitroglycerin Preparations

Antifungals Anticonvulsants Antiplatelet agents

Antivirals Antidepressants Anticoagulant agents

Ophthalmic Preparations Rheumatoid Arthritis Agents Oral Steroids

Respiratory Agents Antiarrythmics Thyroid Hormones

Diabetes Hypotensives Multiple Sclerosis Agents

Parkinsons Agents Otics Select Pancreatic Enzymes

*This list may not be all inclusive and is subject to change

A full list is available by following the links at https://tnm.rxportal.sxc.com/rxclaim/portal/preLogin

Prescriber Attestation Drug Categories The Prescriber Attestation Drug list includes approximately 500 medications in 20 drug categories.

https://tnm.rxportal.sxc.com/rxclaim/portal/preLogin


Did you know that UnitedHealthcare Community Plan Online offers physicians and other health care professionals the ability to see the TENNderCare EPSDT Screening Measures Report and Preventive Health Screening Measures Report online? To register and/or view the UnitedHealthcare Community Plan provider portal and reports, go to UHCCommunityPlan.com/health-professionals/TN/members-information and click on Access secure provider website under UnitedHealthcare Community Plan for families. Follow links to register and/or log on.

Did you know that you also have the option to search by member for both of these reports? Click on either the “TENNderCare EPSDT Report by Member” link or “PHM Report by Member” link to view an individual report for a member enrolled in your panel. You may search for an individual member by Community Plan Member ID Number or Member Name, Last Name and Date of Birth. Searching by Member ID Number is the fastest and most accurate search method.

Did you know that UnitedHealthcare Community Plan Online allows you to notify the health plan with questions regarding data on the TENNderCare EPSDT or Preventive Health Measures report, such as dates of screening? The goal is to facilitate communication relating to reports that are available for providers. To submit a query or comment to the health plan, click the notify plan link, enter and submit form information/comment relating to the TENNderCare EPSDT Screening or Preventive Health Screening Measures Report. An email will be sent to the EPSDT/Preventive Health and Education Department and providers will receive a reply within three to five business days.

To access our policies, Provider Administration Manual, handouts, forms, and recent newsletters and e-Alert notices sent to providers, go to UHCCommunityPlan.com, and click on Health Professionals and select the state of Tennessee under Already Part of Our Network.

Inside the Star Rating Initiative With James Carney, MD, MBAAs UnitedHealthcare’s National Medical Director for Physician Engagement for Medicare Solutions, Dr. Carney plays a lead role with others in developing and communicating strategies to aid physicians in supporting their patients to live healthier lives and manage chronic conditions by obtaining recommended preventive care screenings.

Why Star Ratings Matter for Quality of Care “UnitedHealthcare’s mission is to help people live healthier lives. The Centers for Disease Control and Prevention (CDC) report that screenings and preventive care services continue to be under-utilized. Star ratings emphasize patient care and satisfaction, using national clinical quality measures – including screenings and preventive care and service quality measures – as well as patient feedback, so that health plans, physicians and members can work together to improve individual and total population quality of care and experiences,” said Dr. Carney.





















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UnitedHealthcare Approach According to Dr. Carney: “UnitedHealthcare has dedicated enterprise-wide resources and personnel to work together to create a proactive member engagement, physician engagement and operational excellence approach to support Star Ratings improvement.

This initiative promotes transparency about Star Ratings and is intended to provide physicians with information, tools such as View 360, and incentives that support the additional time and resources they need to strengthen the physician-patient relationship and to help them deliver high quality, comprehensive, affordable health care services.

Our approach is patient-centered and focuses on coordinated care for members to help them understand their benefits and receive the care they need to live healthier lives.”

About Dr. CarneyDr. Carney began his career in the National Health Service Corps as an Internist working in under-served communities in Kentucky and Maryland. Later, he practiced in a staff model HMO, and then a small group practice in Delaware and Pennsylvania. He lives in Richmond, Virginia with his wife and is the father of two adult daughters.

To live a healthier life, Dr. Carney plays golf and tennis. His personal health goals include: maintaining a healthy body weight and an acceptable cholesterol profile to lower the risk for coronary artery disease; eating a well-balanced diet; and promoting overall physical mobility in order to stay active.

Electronic Data Interchange: Save Time and MoneyDid you know by converting 10,000 paper claims, remittance advice, and reimbursements to electronic transmittal (EDI, EFT, and ERA) we could:

• Save 3,729 pounds of paper• Eliminate 148,389 pounds of greenhouse

emissions (Equivalent to 1726 new trees grown for 10 years or 20,451 square feet of forest conserved)

• The average practice can save thousands of dollars per year by converting to electronic transmission.Source: payitgreen.org

Getting Started With EDI is Simple To submit claims electronically simply contact your clearinghouse or software vendor and request that Primary and Secondary UnitedHealthcare Community Plan Claims be sent electronically. UnitedHealthcare Community Plan Claims Payer ID is 87726.

Submit Claims Directly to UnitedHealthcare Community Plan You can access our Secure Provider Portal by visiting the claims and member section of your state’s home page located on UHCCommunityPlan.com. There is no cost for this service.





















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http://payitgreen.org




COB (Secondary) EDI Claims Submissions are Preferred Electronically

• Please visit the EDI Section of Your state’s home page and reference the 837 Companion Guide located on UHCCommunityPlan.com. Share the setup guidelines with your clearinghouse or software vendor.

• Do not send paper claim backup for claims that have already been submitted electronically.

Receive Payment for Claims Electronically (EFT)EFT is safe, secure, efficient, and more cost effective than paper claim payments.

If you would like to save money and time, enroll today! Enrollment forms can be found within the EDI Section of your state’s home page located on UHCCommunityPlan.com.

Receive Remittance Advice Electronically (ERA)To enroll in ERA contact your software vendor and/or clearinghouse. UnitedHealthcare Community Plan ERA Payer ID is WID01.

United Healthcare Community Plan now offers Real-time 270/271 Electronic Health Care Eligibility Inquiry and Response Transactions and Real-time 276/277 Electronic Health Care Claim Status Inquiry and Response Transactions as a quick and easy way to streamline administrative tasks.

This information is also available through the Secure Provider Portal and by phone, however real time transactions save your office that added step.

Please see the Companion Guides located within the EDI Section on your state’s home page on UHCCommunityPlan.com for setup guidelines.

For additional information please contact OptumInsight HIN Sales Team at 800-341-6141 option three.

Electronic Claim Submission Tips• Include your tax identification number

(TIN) along with your NPI number. • Member ID Numbers are required. • The Payer ID number indicates where

clearinghouses should direct their claims.

Quality Improvement ProgramTo continuously improve the care and services provided to members, UnitedHealthcare Community Plan uses Healthcare Effectiveness Data and Information Set (HEDIS) reporting to measure our health care performance. HEDIS is a set of standardized performance measures that are related to many significant public health issues. Nationwide, our HEDIS 2012 scores demonstrated improvements in the number of our adult members who had their body mass index (BMI) screened, an increase in follow-up visits following hospitalizations for mental illness, and an increase in diabetic HBA1c and LDL testing.

UnitedHealthcare Community Plan will continue to target multiple areas for improvement in 2012 through national initiatives including, the number of yearly well visits received by children ages three to six, the number of timely prenatal and postpartum visits, and proper patient use of asthma medications.

We also conduct annual member surveys to see how well we are meeting our member’s needs. Our 2011 Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys showed improvement in how our members rate their personal doctor, the specialists they see most often, and their overall





















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health care. Members told us that they want it to be easy to get approvals for the tests and treatments they need through their Health Plan. We listened and in 2012 are working to improve processes in our prior authorization center.

If you would like further information about our Quality Improvement Program, our annual goals or our progress towards meeting our goals, please call 888-362-3368.

Pharmacy UpdatesPharmacy Updates are available at UHCCommunityPlan.com. The pharmacy hotline is 800-922-1557.

Global Days Policy Reminder If you have received a denial for ‘Payment Being Included in Allowance for Another Service’ before filing an appeal, please reference the Global Days Policy. The full plan is available on-line at UHCCommunityPlan.com/assets/Global-Days-Policy-(R0005)-1-1-11.pdf.

A few reminders follow:

• Pre-operative visits are not separately reimbursable services when performed within the assigned global period.

• Major Procedures: 90-day global value begins with the day before surgery.

• Minor Procedures (global value other than 90 days): Global period begins the day of surgery.

• Complications following a procedure, including all additional medical and/or surgical services required of the physician (not resulting in a return trip to the operating room) that occur within the designated global period are included in the Global Package.

• Procedures having a zero-, 10- or 90-day global value that are performed during the post-operative period of a procedure having a 10- or 90-day global value are considered to be included in the Global Package of the initial procedure unless an appropriate modifier is appended.

• 58 – Staged or related procedure or service by the same physician during the post-operative period.

• 78 – Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the post-operative period.

• 79 – Unrelated procedure or service by the same physician during the post-operative period.

• Services of physicians and other health care professionals of the same specialty within and using the same federal tax identification number are deemed as performed by the same physician providing global period services.

UnitedHealthcare Community Plan Evaluation & Management Services included in the global period are listed within policy as well as the global day values. If you have any questions, please contact Provider Services at 800-445-1638 or your local Provider Advocate.





















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http://UHCCommunityPlan.com/assets/Global-Days-Policy-(R0005)-1-1-11.pdf

http://UHCCommunityPlan.com/assets/Global-Days-Policy-(R0005)-1-1-11.pdf


Updated Information About 17 Alpha Hydroxyprogesterone Caproate (17P) InjectionUnitedHealthcare Community Plan has updated its drug policy for use of 17 alpha-hydroxyprogesterone caproate (17P) injection, encompassing both the compounded drug and Makena, effective Oct. 1, 2012.

UnitedHealthcare’s Policy Regarding Compounded 17P and MakenaUnitedHealthcare understands the importance of access to 17P and we continue to support the physician’s discretion to use either compounded preservative-free 17P if the prescribing practitioner has determined that a compounded product is necessary for the particular patient and would provide a significant difference for the patient as compared to the FDA-approved commercially available drug product, or Makena.

Relying on evidenced-based medicine and outcomes-based research, UnitedHealthcare has updated its drug policy for use of 17 alpha-hydroxyprogesterone caproate (17P) injection, both the compounded drug and Makena, effective Oct. 1, 2012. This policy applies to Commercial, Medicare and Community Plan business.

Options for providing 17P to Patients who are UnitedHealthcare Community Plan Members

• State Fee-for-Service Pharmacy Program Some members of UnitedHealthcare Community Plan have pharmacy benefits that are not processed through UnitedHealthcare Community Plan, but through the state’s fee-for-service

program. Providers in Louisiana, Tennessee and Wisconsin should contact your State Medicaid Agency to determine the state’s requirements, preferred pharmacy vendor and process for ordering 17P or Makena.

• Home Health Services UnitedHealthcare has a preferred relationship with the Women’s and Children’s Health division of Alere Health. This home health service offers a compounded, preservative-free 17P administration program, which includes in-home obstetric nurse administration, education about the risk factors and signs and symptoms of preterm labor, weekly assessments and 24/7 nurse-line support. For more information please contact Alere at 800-950-3963 or alere.com.

• Buy-and-Bill for Compounded 17P Compounded, preservative-free 17P can be located in your area by calling or visiting the International Academy of Compounding Pharmacist Locator Service at 800-927-4227 or iacprx.org. Compounding pharmacies will continue to compound 17P as long as the prescribing practitioner has determined and documented that a compounded product is necessary for the particular patient and would provide a significant difference for the patient as compared to Makena.

• Reimbursement for Buy and Bill for Compounded 17PFor providers who administer compounded, preservative-free 17P in their office through the buy-and-bill process, reimbursement is achieved by submitting a medical claim for the medication HCPCS code-J2675 progesterone injection, per 50 mg (bill 5 units per injection-250 mg/injection)





















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http://www.alere.com/us/en.html

http://iacprx.org/





















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with the CPT code-96372 for therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular, and the diagnostic code V23.41- supervision of pregnancy with history of preterm labor. Please contact your local provider relations representative or call provider customer service if you have questions about reimbursement.

• Pharmacy Direct Bill UnitedHealthcare Community Plan for MakenaMakena can be obtained from either Prescription Solutions by OptumRx or CVS Caremark Specialty Pharmacy, depending upon the state. Please refer to the table.

Makena Vendors – UnitedHealthcare Community PlanPlease consult the table below to determine which pharmacy is the designated UnitedHealthcare Community Plan vendor for Makena in your state.

Contact informationCVS Caremark Specialty Pharmacy phone: 800-237-2767 fax: 800-323-2445Prescription Solutions by OptumRx phone: 888-293-9309 fax: 800-853-3844

State VendorArizona OptumRx

Delaware CVS Caremark Specialty Pharmacy

District of Columbia CVS Caremark Specialty Pharmacy

Florida CVS Caremark Specialty Pharmacy

Hawaii CVS Caremark Specialty Pharmacy

Iowa OptumRx

Kansas OptumRx Effective Jan. 1, 2013

Louisiana Contact State Medicaid Agency

Maryland OptumRx

Michigan OptumRx

Mississippi CVS Caremark Specialty Pharmacy

Nebraska CVS Caremark Specialty Pharmacy

New Jersey OptumRx

New Mexico OptumRx

New York CVS Caremark Specialty Pharmacy

Ohio CVS Caremark Specialty Pharmacy

Pennsylvania CVS Caremark Specialty Pharmacy

Rhode Island OptumRx

South Carolina CVS Caremark Specialty Pharmacy

Tennessee Contact State Medicaid Agency

Texas CVS Caremark Specialty Pharmacy

Washington OptumRx

Wisconsin Contact State Medicaid Agency



Prior AuthorizationUnitedHealthcare Community Plan requires prior authorization for compounded 17P or Makena whether administered in the office or by a home health service.

• Prior Authorization for Compounded 17P Please submit the UnitedHealthcare Community Plan’s standard medical prior authorization form with supporting documentation (documents regarding prior premature deliveries [e.g., delivery notes, discharge summaries that state gestational age at time of delivery, the reason for the premature birth], current gestational age) to the fax number listed on the form. If authorized, you will be issued an authorization number that you will need to provide to the pharmacy.

• Prior Authorization for MakenaPlease submit the UnitedHealthcare Community Plan’s standard medical prior authorization form with supporting documentation (documents regarding prior premature deliveries [e.g., delivery notes, discharge summaries that state gestational age at time of delivery, the reason for the premature birth], current gestational age) to the fax number listed on the form. If authorized, you will be issued an authorization number that you will need to provide to the pharmacy. Upon completion of the manufacturer’s standard Makena Referral/Prescription form, place the authorization number on the top and submit via fax to the specialty pharmacy provider identified for your state (see table on page 13). These specialty pharmacy providers will bill UnitedHealthcare Community Plan directly.

Direct Billing For a complete list of pharmacies that will ship to you and bill UnitedHealthcare Community Plan directly and for more information on this policy go to UnitedHealthcare Community Plan 17P and Makena Drug Policy.

Recovery and AdherenceClinicians want individuals in their care to get better and believe that if the treatment plans they offer are followed their patient’s condition will improve. Yet treatment plans don’t work when patients don’t adhere to them. The connection between a lack of adherence and negative outcomes seems obvious, yet the World Health Organization (2003) states that for chronic illness, only 50 percent of patients adhere to their long-term therapy in developed countries.

Do the principles of recovery and resiliency offer any insights and support to approaching this problematic disconnect? There are several insights that can be adapted in most practices to help bridge this gap.

Focus on Strengths, Goals Spend time on where patients are going and not where they are stuck.A recovery-directed conversation with a patient focuses on individual strengths and personal goals rather than symptom severity or being sick. A conversation that focuses primarily on symptoms may further the negative self-image and sense hopelessness contributed to chronic illnesses. When a conversation includes a clear focus on the patient and their personal goals, and frames medication as one strategy toward meeting those goals, the individual is often more motivated and hopeful.





















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http://www.makena.com/media/PDFs/referral-prescription-form.pdf

http://www.makena.com/media/PDFs/referral-prescription-form.pdf




Educate More, Direct LessA recovery oriented interaction in each appointment provides education on treatment — including addressing widely held, but inaccurate beliefs about medication. Of critical importance is putting written educational materials in patient’s hands. Written material supports different learning styles and affords an opportunity to easily share information with support networks.

Acknowledge Challenges and Invite ParticipationIt helps for patient’s to hear that many people find it very hard to take medicine regularly. Let them know that you want to hear the particular challenges they face in using medicine as a tool in their recovery plan. Inquiring about challenges lets patients know that you are committed to working with them toward solutions.

Support Engagement Through Tools and Community Resources Engagement is not synonymous with compliance. Compliance means an individual obeys a directive from a health care provider. Engagement signifies that a person is involved in a process through which he harmonizes robust information and professional advice with his own needs, preferences and abilities in order to prevent, manage and cure disease1.

Connecting members to local community resources can reduce isolation and increase treatment adherence. Links to reputable support groups can be found on our member portal. Tools like the Wellness Recovery Action Plan® (WRAP) have been shown to significantly enhance skills for coping with prodromal symptoms, use of wellness tools in

their daily routines, and hope for recovery2. A free version of WRAP can be downloaded from the Substance Abuse and Mental Health Services Administration (SAMHSA) web site.

SAMHSA recently issued this definition of recovery:

A process of change through which individuals improve their health and wellness, live a self-directed life and strive to reach their full potential.

SAMHSA further states:

Recovery involves individual, family, and community strengths and responsibility: Individuals, families, and communities have strengths and resources that serve as a foundation for recovery. In addition, individuals have a personal responsibility for their own self-care and journeys of recovery. The full article is available on the SAMHSA blog posting March 23, 2012.

These four simple tips reflect a recovery oriented way to support increased adherence while building a treatment plan that incorporates the patient’s own strengths and goals while providing them with the information and support they need to achieve those goals.

By Sue Bergeson, Vice President of Consumer Affairs

1 A New Definition of Patient Engagement: What is Engagement and Why is it Important?, Center for Advancing Health © 2010 http://www.cfah.org/pdfs/CFAH_Engagement_Behavior_Framework_current.pdf.

2 Cook, J. A., Copeland, M. E., Hamilton, M. M., Jonikas, J. A., Razzano, L. A., Floyd, C. B., et al. (2009). Initial outcomes of a mental illness self-management program based on Wellness Recovery Action Planning. Psychiatric Services, 60(2), 246-249.





















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http://www.cfah.org/pdfs/CFAH_Engagement_Behavior_Framework_current.pdf

http://www.cfah.org/pdfs/CFAH_Engagement_Behavior_Framework_current.pdf

Tennessee

Provider Service Center: 800-557-9933

Practice Matters is a quarterly publication for physicians and other health care professionals and facilitiesin the UnitedHealthcare network.

M47507MS 8/12 © 2012 UnitedHealth Group, Inc. All Rights Reserved.

795 Woodlands ParkwaySuite 301Ridgeland, MS 39157


UnitedHealthcare Community Plan now offers Real-time 270/271 Electronic Health Care EligibilityInquiry and ResponseTransactions and Real-time276/277 Electronic Health Care Claim Status Inquiryand ResponseTransactions as a quick and easy way tostreamline administrative tasks..

This information is also available through the SecureProvider Portal and by phone, however real timetransactions save your office that added step.

Please see the Companion Guides located within theEDI Section on your State’s home page onUHCCommunityPlan.com for setup guidelines.

Electronic Claim SubmissionTips• Include your tax identification number (TIN) alongwith your NPI number.

• Member ID numbers are required.

• The Payer ID number indicates where clearinghousesshould direct their claims.

8 Cadillac DriveSte. 100Brentwood, TN 37027

M47507TN 11/12 © 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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